Learning musculoskeletal anatomy through new technologies: a randomized clinical trial*

Objective: to investigate the influence of the application of new methodologies on learning and the motivation of students of the Anatomy discipline. Method: randomized, longitudinal, prospective, intervention study. Sixty-two students were recruited to assess the impact of different methodologies. The sample was randomized to compare the results of teaching with a 3D atlas, ultrasound and the traditional method. The parameters were assessed through a satisfaction evaluation questionnaire and anatomical charts. Repeated measures ANOVA was used to determine statistical significance. Results: in terms of the usefulness of the seminars, 98.1% of the students considered them to be very positive or positive, stating that they had stimulated their interest in anatomy. The students who learned with the 3D atlas improved their understanding of anatomy (p=0.040). In general, the students improved their grades by around 20%. Conclusion: the traditional method combined with new technologies increases the interest of students in human anatomy and enables them to acquire skills and competencies during the learning process.


Introduction
Human anatomy courses are obligatory in every year of Health Sciences programs. Studying and understanding the subject requires different skills on the part of students, as well as considerable effort to consolidate their knowledge of the different body structures, communication through precise technical language and adequate body spatial orientation. There is a complex balance between knowledge acquisition, skills and learning results. It is challenging and necessary for professors to upgrade their skills in order to improve the quality of their teaching.
The learning process, combined with the challenge of memorizing relevant information, also involves the skill of using resources to find, assess and apply this information. However, the volume of content in the subject of anatomy leaves students little time to improve their understanding and integration of concepts (1) .
Lectures are effective for transmitting information and guiding study programs (2)(3) , however, numerous studies have found that using different methodologies, such as problem-based teaching, practices and other types of participatory methodologies carried out in groups, strengthens the integration of knowledge acquired during lectures (4) . This is particularly relevant in subjects such as human anatomy, where textbooks reflect a different reality than the possibility of observing anatomical structures in real time through ultrasound (5) .
Those who study anatomy with the help of imaging techniques develop a positive perception of the subject that is not only short-term but lasts for years (4) .
For this reason, the issue needs to be addressed in today's university community, due to the growing demand of students who want to enhance their professional profiles in the clinical realm, with a curriculum increasingly oriented toward new technologies. To this end, a program was designed, comprised of different teaching methodologies in appropriate proportions, to maximize both knowledge acquisition and the development of skills. It also sought to develop a yardstick for measuring learning that assesses knowledge acquisition, combined with those competencies related to the subject. In line with the above, the present study was based on the hypothesis that educational interventions with new methodologies represent an effective strategy for enhancing knowledge of musculoskeletal anatomy. The purpose of this study was to investigate the influence of the application of new methodologies on learning and the motivation of students of the Anatomy discipline.

Method
A randomized, longitudinal, prospective, intervention study was conducted. The study was implemented over a period of eight weeks. Sixty-two students (20 women and 42 men) in their first year of the Physiotherapy and/or Nursing program of Camilo José Cela University were recruited to assess the impact of an innovative methodological approach, constituting an experimental strategy. The students participated voluntarily and every candidate who expressed interest in being part of the study was included. They were invited to attend seminars, with each session lasting 90 minutes. The methodology involved comparing the results obtained from a study group that used a 3D atlas (n=23), another study group that used ultrasound (n=20) and a control group that received traditional lectures (n=19). The teaching staff was shared among the three groups. The groups were assigned according to the group of practices to which each student belonged, and the methodology selected for each group was randomly decided by the teaching staff.
The randomization process was done through a random numbers table generated by the software Epi Info version 7.1.4. None of the students were familiar with the teaching methodology that would be applied to them.
The control group was administered the content according to a traditional lecture-based methodology, using anatomy textbooks for the different regions and their planes, in addition to palpation. In the 3D atlas study group, a mixed methodology was applied, composed of lectures and a 3D atlas, and the palpation activity followed the seven-step method (6) . As for the ultrasound study group, a mixed methodology was also applied, with lectures and ultrasound, and palpation practices were carried out with ultrasound. The topics and number of hours for each group were the same. The study was conducted in accordance with the ethical standards of the Declaration of Helsinki (7) , and the patients' data was kept confidential (8)   Regarding the data obtained for the primary objective, the mean score of the students for the charts before the seminars was 3.46 ± 1.8 points out of ten, the highest rate of correct answers was in relation to the lateral compartment of the leg chart  The interactive style of the seminar was scored as very positive (63.5%) or positive (32.7%) by the students.
All the students felt that the seminar should be repeated for another anatomical region. There were no significant differences among the different groups in the assessment of the items from the satisfaction evaluation questionnaire (p>0.005), except for the question "Did the seminar improve your understanding of anatomy?" where there were significant differences between the groups (χ² [4]=10.05; p=0.040): 46.4% of the students who were taught through a 3D atlas, 17.9 % who used ultrasound and 35.7% who received traditional teaching scored this aspect as very positive.

Discussion
Students feel overwhelmed by the large volume of information they receive throughout the course (10)(11) .
Incorporating new technologies into anatomy classes enables viewing the system in vivo and improves students' understanding of the spatial relationship and orientation among various anatomical structures (12) . In this study, the mean percentage of the scores in the satisfaction evaluation questionnaire indicated that the students considered the use of new technologies as highly advantageous in their learning process. Since the use of mixed methodologies, involving a combination of textbooks, online material and videos, among others, facilitates understanding and the acquisition of skills and competencies, it can be concluded that this approach deepens anatomical knowledge and its clinical application (13)(14) .
The results of this study shed greater light on the question as to whether teaching with new technologies fosters and increases interest in human anatomy. The data from the present study, as in other studies (15)(16)(17) , Similar studies have been conducted with medical, nursing and podiatry students (18,19) . There was a greater diversity in the sample of the present study since, even though they were all physiotherapy and/or nursing students, around 60% had prior university studies. anatomical structures during palpation (9,22) .
It is for this reason that, for years, various studies have sought to demonstrate the usefulness of ultrasound as a supplementary method for studying anatomy, with promising results (23)(24)(25)(26)(27)(28) , even though a recently published review concluded that further investigation is necessary in this regard (29) .
In relation to the influence of new technologies on the anatomical learning process, the students increased their number of correct answers by 20%, with results similar to other studies (13) , but differing from the findings of another study (19) , although it was concluded in the latter that technological improvement of the simulator used could be decisive for obtaining results similar to those in the present study. It should be noted that the highest rate of improvement occurred in the control group, which suggests that, despite the review in the aforementioned studies, the traditional method may be the most appropriate for enhancing the academic performance of students.
The limitations of the study were sample size, as well as the quantification of learning and short-term

Conclusion
The use of new technologies, as a support to traditional teaching methods in human anatomy courses, increases the interest of students and enables them to acquire skills and competencies in their learning process. The three teaching methodologieslectures, 3D atlas and ultrasound -suggest a potentially beneficial effect on learning human anatomy, without finding any differences between them. This study emphasizes the importance of compiling students' preferences in order to optimize the teaching methods used in human anatomy study plans.