ABSTRACT: The purpose of this study was to determine the effectiveness of computer-assisted instruction (CAI) to teach the anatomy, biomechanics, and pathomechanics of the temporomandibular joint (TMJ). Sixty-six first- and second-year physical therapist students at Southwest Texas State University participated. None of the subjects had received instruction on the TMJ prior to this study. A two-group pretestposttest experimental design was used. Each group consisted of IS first-year students and IS second-year students. The control group was taught the TM>information by traditional lecture format using still pictures via overhead transparencies for visual illustration. The experimental group was taught the TMJ information using traditional lecture format and CAI with dynamic graphics capabilities. Two faculty members presented the same lecture to both groups, with visual representation of the material being the only variation. Each student completed a pretest consisting of 25 multiple-choice questions pertaining to TMJ anatomy, biomechanics, and dysfunction. Immediately following instruction, each student completed a posttest, identical to the pretest except for random ordering of the questions. A univariate analysis of covariance (ANCOVA), with pretest scores as the covariate and posttest scores as the dependent variable, was performed for the student groups. Posttest scores were not significantly different between students taught by lecture and those taught by lecture using CAI, regardless of level of education. However, posttest scores were significantly different between first- and second-year students, regardless of method of instruction. Findings implied that second-year students were better prepared to understand the information being taught. The results of this study showed the use of the traditional lecture method and lecture supported with CAI to be equally effective in teaching information related to the TMJ.
Recent advances in instructional technology provide educators with a range of exciting and versatile teaching tools. Today's microcomputer programs are capable of demonstrating intricate patterns of movement that can readily enhance a student's ability to visualize complex concepts. Because of this, computerassisted instruction (CAI) is gaining popularity as an effective and efficient method of teaching in a wide range of health-related education programs. 1-5 The effectiveness of CAI use is debatable, however, because published utilization studies have yielded inconsistent results. Inasmuch as researchers have found inconsistent findings regarding the effectiveness of CAI, many advantages are linked to its use.
Benefits associated with CAI include the ability to provide individualized instruction,6-io immediate feedback,4,6-9,11-14 selfpaced learning,4,8 17 freedom of faculty time,3,6,11,18 instructional accessibility,6,10,11 and experience with developing problem-solving skills.6,7,11,13,,19 A particularly effective component of CAI is the ability to incorporate graphics to illustrate visual concepts.5,6,13,20,24
The capability of using still pictures and moving graphics to portray concepts and demonstrate movement patterns is thought to be one of the more valuable components of CA122 and is believed to enhance student learning.25,26 Visual concepts, which may otherwise be difficult to present, can be more effectively conveyed using pictures, diagrams, and moving graphics.1,5,24,26 Graphicsenhanced CAI is especially useful to teach subjects such as anatomy and biomechanics because of the visual and dynamic nature of the subject matter.22
Faculty members in physical therapist education often encounter the challenge of using verbal descriptions, supplemented with static musculoskeletal models and diagrams in textbooks, to facilitate understanding of dynamic human movement. Computer-assisted instruction, enhanced with graphics, can demonstrate movement in a realistic fashion, thereby complementing traditional methods of instruction. However, the availability of graphics-enhanced CAI is limited, and the paucity of visually driven instruction has been deemed problematic.2.27 The lack of available programs appropriate for physical therapist education has been identified as the greatest limitation to use of CAI in the physical therapist professional curricula.11
Computer-assisted instruction is often presented for use as an alternative method of teaching to more traditional forms of instruction. However, much of the literature recommends that CAI be used as an adjunct to, rather than a replacement for, traditional teaching methods.1,2,16,24,28 Furthermore, a caveat exists that CAI not be considered a better teaching method than traditional forms of instruction, primarily because research findings on the effectiveness of CAI have been inconclusive.2 Inconsistent findings result, in part, because many studies fail to include adequate control groups. A primary criticism of CAI has been the lack of experimental studies to evaluate its effectiveness as an educational tool.2,13,22
The focus of this research was the development and evaluation of a graphics-enhanced CAI program for use in physical therapist education. The effectiveness of the graphicsdriven program, specifically designed for use as an adjunct to teach the anatomy, biomechanics, and pathomechanics of the temporomandibular joint (TMJ), was evaluated in a controlled study of 66 first- and second-year physical therapist students. We hypothesized that there would be no difference in test performance of physical therapist students between instructional methods (traditional lecture versus lecture with CAI) used to teach the anatomy, biomechanics, and pathomechanics of the TMJ.
REVIEW OF THE LITERATURE
The use of CAI as a primary or adjunctive tool for teaching in health care professions education has steadily increased over the past two decades. Published studies are available on use of CAI in medicine,2,23,29 dentistry,2,29 nursing.1,2,7,13,29,30 pharmacology,2,4,29 radiation therapy,5,29 respiratory therapy,2,3,17,29 and occupational therapy.2,22 Published reports on CAI designed specifically for use in physical therapist education are few in number and include programs to teach therapeutic exercise,31 patient management,l2 sliding board transfers,l4 muscle tension physiology,20 brachial plexus lesions,15 rheumatology,26 respiration,32 and evaluation and treatment skills for carpal tunnel syndrome.10
Kosmahl11 found that only 29.9% of entrylevel physical therapist education programs used CAI as a teaching tool, a substantially lower percentage than reported by nursing and other allied health programs.2,7 One reason for the low levels of CAI use in the profession is limited availability of programs appropriate for physical therapist education.ll Furthermore, the lack of graphics-enhanced CAI is implicated as an impediment to the effective use of CAI." Only three studies related to graphicsenhanced CAI in physical therapist education have been published. These include programs designed to teach sliding board transfers,14 rheumatology,26 and brachial plexus lesions. 15 Although the benefits of graphics have been routinely expressed, the availability of graphics-enhanced CAI programs is a notable limitation, and the development and use of more CAI programs with visual illustrations are strongly recommended.2
Caution is warranted, however, for simply promoting the development and use of more CAI programs,2,13,22 and graphics-enhanced CAI programs in particular.27 That is, concern exists over the lack of controlled studies to determine the effectiveness of CAI as an instructional tool. Given the number of CAI programs currently available for use in healthrelated education, little documentation exists on experimental studies performed to learn about the effectiveness of this instructional medium.
Nursing education leads the health care fields in publishing experimental studies related to use of CAI as a teaching tool.l3,29 Similar publications are available in the fields of radiation therapy,5 respiratory therapy 17 and occupational therapy.22,24 Jelovsek and Adebonojo29 comprehensively reviewed 41 clinical studies of CAI use in health-related fields; only one study, published by Thompson, was in the field of physical therapy.
Thompson compared the effects of using CAI versus written programmed text to teach respiration to physical therapist students and found no significant difference between the two methods of teaching.32 Additionally, three controlled studies conducted on the use of CAI in physical therapist education have been published. Barker14 found no significant difference in written examination scores and motor performance between preprofessional physical therapist students learning the sliding board transfer. Likewise, Kinney et al10 found no significant difference in posttest scores when comparing the use of CAI with interactive lecture when teaching evaluation and treatment skills for carpal tunnel syndrome. Sanford et al26 studied the effects of using videodisc to teach rheumatology to physical therapist students and occupational therapy students. The CAI used in this study included a graphics component, which interestingly, was linked to the study's only significant finding. However, a nonequivalent control group design was used in this study, which the authors identified as a potential point of criticism.
Computer-assisted instruction is also thought to be an effective teaching tool, especially when used as an adjunct to support traditional methods of instruction.1,2,5,8,15-17,24,26,28,30 Paulanka30 suggested that an important component of CAI is the presence and participation of faculty in the teaching process. Although the use of CAI is recommended as a tool to support traditional teaching,26 most published reports evaluate CAI as a replacement for, or independent of, traditional teaching. To date, no studies have been published that focus on CAI specifically as an adjunct to traditional instruction in physical therapist education.
The purpose of this study was to compare the effectiveness of traditional lecture instruction, supported with a graphics-enhanced CAI program, with traditional lecture instruction alone to teach anatomy, biomechanics, and pathomechanics of the TMJ to physical therapist students.
BIOMECHANICS INSTRUCTION USING CAI
Because of the nature of biomechanics, traditional methods of teaching biomechanics that use lecture instruction alone are inadequate. It is difficult to effectively explain subtle movements and joint dynamics using verbal descriptions and static picture illustrations. Faculty often liken biomechanics instruction to requiring students to develop xray vision in order to see inside the human body while it functions. Static illustrations of movement are often used to depict movement patterns, but they can neither realistically replicate pathological motion nor demonstrate tissue responses to positional change. Laboratory sessions, corresponding to lectures, can be designed to help students examine and understand gross movements, but the study of osteokinematic movement does not disclose what is happening to the internal joint structures of bone, tendon, and ligament.
Computer-assisted instruction graphics provide the capability of peeling away skin and tissue to allow the student to view the architecture of the deeper underlying structures. Color-enhanced moving graphics can simulate both normal and pathological joint motion and the corresponding response of surrounding tissues. Such graphics allow the student to visually analyze the intricate structural interplay during functional movement, while enhancing the student's comprehension of human motion, and thereby facilitate a clearer understanding of biomechanical function.
DEVELOPMENT OF BIOCAT
Physical therapy faculty at Southwest Texas State University, in collaboration with health and kinesiology faculty at Texas A&M University, developed a lesson using CAI to teach students about the TMJ. The lesson, BIOmechanics With Computer-Assisted Technology (BIOCAT), is a graphics-driven program designed to teach the anatomy, biomechanics, and pathomechanics of the TMJ. BIOCAT was designed for use as an instructional adjunct to facilitate understanding of relatively complex information related to biomechanical function of this joint.
BIOCAT was developed using the Macintosh MacroMind Director Program, incorporating video, audio, and moving graphics. Short video segments of a human subject were included to demonstrate normal osteokinematic motion. Sequential pictures of internal joint structures and motion, scanned together, were used to demonstrate bony and soft tissue relationships during normal and pathological arthrokinematic motion. When touched by the mouse-driven cursor, anatomical structures are identified on colored, static pictures. All segments of the program were appropriately ordered under four categories within a main menu, which contain the topics of anatomy, osteokinematics, arthokinematics, and pathomechanics.
Sixty-six first- and second-year physical therapist students from an entry-level master's in physical therapy degree program voluntarily participated in the study. The subjects were 26 males and 40 females. Thirty participants were first-year students who entered the physical therapist program 2 weeks prior to the study. The 36 second-year students who participated had completed course work addressing anatomy, kinesiology and basic orthopedic assessment, and treatment techniques for the lower extremity and spine, but had not yet received similar course work related to the upper extremity or TMJ. All students received a letter of explanation approved by the Institutional Review Board at Southwest Texas State University and signed a form of consent for participation.
This study used a two-group pretestposttest experimental design. Students were randomly assigned to one of two groups of 33 subjects, with each group consisting of 15 first-year students and 18 second-year students. The control group received traditional lecture instruction on the anatomy, biomechanics, and pathomechanics of the TMJ by two physical therapy faculty members, who used overhead transparencies for visual representation of the material. The experimental group received the same instruction, in the same amount of time, by the same faculty members, using BIOCAT for visual depiction of the information.
Many of the pictures used to illustrate the anatomy and depict movement consisted of original drawings used to create BIOCAT. The same pictures were presented to both the control and experimental groups during the lectures, the difference being the manner in which the pictures were presented. Pictures shown to the control group were static illustrations placed on overhead transparencies. The experimental group viewed pictures as dynamic movement, made possible by scanning series of pictures together on the computer to illustrate osteokinematic or arthrokinematic motion (Figure). In addition, BIOCAT contained other features that included video segments of normal TMJ movement using asymptomatic subjects and sound to replicate the characteristics that often accompany the pathomechanics of disk dislocation.
A 25-question multiple-choice test was created by the two faculty members who taught the TMJ material. The test contained questions that addressed the anatomy, biomechanics, and pathomechanics of the TMJ. The test served as the pretest and the posttest, with a random ordering of questions between tests as the only variation.
Each student completed both a 25-question multiple-choice pretest 2 days prior to attending a lecture on the TMJ and a posttest immediately following presentation of the TMJ material. Individual scores were calculated on a percentile basis for further analysis and comparison. The lectures were given during back-to-back time slots on the same day in order to reduce the potential for discussion of material or teaching methods between groups. Every effort was made to standardize teaching time, environment, and information.
Each lecture session was videotaped and reviewed by a physical therapist graduate student who was not a participant in the study to detect and document any inconsistencies in presentation of material or content of information provided as a result of questions asked or class discussion that ensued during the course of the lectures.
The internal consistency reliability of the 25-item test was determined by computing Cronbach's coefficient alpha. This documented homogeneity of questions asked on the test. The reliability of the test was measured at .69, which was considered acceptable due to the varied nature of the question subjects and the number of questions formulated.
The pretest scores for the control and experimental groups were analyzed by t test for independent samples. A univariate analysis of covariance (ANCOVA), with pretest scores as the covariate and posttest scores as the dependent variable, was run for the student groups. The ANCOVA was used to assess significant differences in posttest scores between the experimental and control groups within their respective class years. The level of significance was set at P<.OS for all analyses.
Results of the pretest analysis revealed no significant difference between the control group mean of 35.3 and the experimental group mean of 35.4 (P=.951) (Table 1). Additionally, pretest scores for first-year students versus the second-year students were subjected to t-test analysis. Although the first-year students' mean was 34.0 and the second-year students' mean was 36.9, this also was not a statistically significant difference (P=.135) (Table 2). Based on similar performances of both groups on the pretest, we were confident that an equivalent level of knowledge regarding the TMJ was demonstrated for all subjects.
The ANCOVA calculated for posttest results demonstrated significance for the effect of year (P=.000), but not for type of instruction received (P=.757) or the two-way interaction of group x year (.488) (Table 3). The hypothesis that there would be no difference in test performance of physical therapist students between instructional methods, therefore, was accepted.
Regardless of instructional method type used, student posttest scores were greater overall when compared with pretest scores; therefore, learning was achieved from both teaching formats. However, we found no significant difference in test performance between the two groups of students receiving the different instructional methods. A significant difference in performance was found between first- and second-year students independent of instructional method. That is, second-year students performed better than first-year students, regardless of whether they received traditional lecture or lecture enhanced with CAI.
Several factors may have affected the results of this study and should be acknowledged. First, the lack of difference found between the control and experimental groups may be attributed to the subtle effect that was being tested. In an attempt to control for confounding variables in addition to studying variables that had not been previously manipulated by other researchers, we may have inadvertently provided too much control. Using the same illustrations to present the information, varying only the manner (static versus dynamic) in which they were presented, may have affected the ability to discriminate a difference in learning effects between the two groups. Had we used pictures and illustrations presented in texts or previous class lectures on the TMJ during the lecture to the control group, the visual presentation of material to the two groups would have been notably different, and, potentially, a difference in student understanding and learning may have been captured.
Second, subjective analysis of the lecture videotapes yielded some potentially useful anecdotal information that may have affected the results. It was noted by the videotape reviewer that fewer questions were asked by the experimental group during and following the presentation. This may have indicated greater immediacy of understanding of the material presented. The control group, however, may have benefited from the interaction with the instructors during discussion following the questions asked. It was also noted that the lights had to be dimmed much more for the CAI presentation than for the traditional presentation to enhance viewing of the graphics in the program, which may have limited experimental group student participation and comfort with getting the instructor's attention to ask questions during the lecture.
Third, the results of this study may have been influenced by the testing instrument and its level of reliability. Multiple-choice questions regarding this subject matter may not have been sensitive enough to pick up on improved understanding of the dynamic concepts being taught. Although an attempt to enhance the teaching of this information was done by developing the CAI module, an equal attempt at developing a comparable testing method should also have been used. The beneficial effects of using graphics to depict dynamic movement patterns are well supported in the literature,1,5,22,24-26 yet these benefits may be more effectively measured by other means such as practical, oral, or even computerized examination, which uses graphics-enhanced illustration. Ultimately, in physical therapy, it is a goal for students to utilize information learned clinically, and that is where such improved understanding may be found.
Finally, although we did not assess the value of using CAI outside of the classroom, doing so may have affected the results of this study. Like other studies performed in physical therapist education on the use of CAI, this study was designed to evaluate CAI following a one-time exposure to CAI in the classroom. Several advantages associated with CAI pertain to its usefulness as an instructional tool to provide instruction outside of the classroom, namely the benefits of instructional accessibility,6,10,11 individualized instruction,6-10 and self-paced learning.4,8 17 Designing the study to capture not only the use of CAI as a teaching adjunct during the lecture session but also its utilization in the laboratory and outside of the classroom would have more readily evaluated its full potential as a teaching tool.
The results of this study are consistent with research findings indicating CAI to be merely equivalent, but not superior, to traditional forms on instruction as measured by student test scores.10,13,14,18,32 This is potentially important information for those considering developing and using CAI; the high costs associated with the development of a CAI module should be weighed against the lack of evidence to support superior learning capabilities when compared with traditional classroom instruction. A great deal of time and collaborative effort were required to develop the BIOCAT module. Given that no evidence was found to support its ability to improve student learning, consideration should be given to determine whether faculty time was best spent in the design and development of a computerized instructional program for the course. If CAI is perceived to enhance course instruction, a strong argument exists for the purchase of commercial CAI programs, which are becoming more readily available and are more sophisticated in design. Although few CAI programs exist on specific physical therapy topics, many basic science, medical, or nursing programs can be adapted for use in physical therapy curricula.
The final point regarding the findings of this study relate to those who rely regularly on CAI utilization. Occasionally, these teachers are forced to revert to traditional backups due to technical failures, and they can be assured that learning will occur despite technical problems encountered that prevent them from using CAI.
We believe the BIOCAT module to be a viable adjunctive teaching tool to demonstrate anatomical structures and dynamic human movement of the TMJ in a more realistic fashion than static pictures alone allow. Alternative methods to assess the effectiveness and perceived usefulness of BIOCAT are recommended to gain greater insight into its use in the classroom and laboratory, as well as its potential as a mechanism to enhance independent student study.
This research was conducted with grant funding received from the Texas Physical Therapy Education and Research Foundation. In addition, we thank two individuals who were instrumental in the development of this project: Max Stratton, MS, provided the computer technical support necessary to create BIOCAT, and Amy Mahloch, MSPT, designed the original artwork used in BIOCAT.
Belfry MJ, Winne PH. A review of the effectiveness of computer-assisted instruction in nursing education. Comput Nurs. 1988;6:77-85.
2. Hmelo CE. Computer-assisted instruction in health professions education: a review of the published literature. Journal of Educational Technology Systems. 1989-1990;18 (2):83-101.
3. McCue P. Computer-assisted instruction in respiratory care education. Respiratory Management. November-December 1987:15-18.
4. Pazdernik TL, Walaszek EJ. A computerassisted teaching system in pharmacology for health professions. Journal of Medical Education. 1983;58:341-348.
5. Rowe JL. The effectiveness of a computerassisted instruction program upon learning the x-ray machine circuit. Radiol Technol. 1989;61:115-118
6. Billings DM. Advantages and disadvantages of computer-assisted instruction. Dimensions in Critical Care Nursing. 1986;5:356 -362.
7. Hebda T. A profile of the use of computer assisted instruction within baccalaureate nursing education. Comput Nurs. 1988;6: 22-29.
8. Bitzer M. Clinical nursing instruction via the PLATO simulated laboratory. Nurs Res. 1966;15:144-150.
9. Johnson G, Gersten R, Carinie D. Effects of instructional design variables on vocab
ulary acquisition of LD students: a study of computer-assisted instruction. Journal of Learning Disabilities. 1987;20:206213. 10. Kinney R, Keskula DR, Perry JR The effect of a computer assisted instructional program on physical therapy students. JAIlied Health. 1997;26:57-61. 11. Kosmahl EM. Instructional use of computers for entry-level physical therapy education. Journal of Physical Therapy Education. 1994;8(1):25-31.
12. Hayes KW, Rogers J, Sullivan JE, Huber G. Computer-base patient management problems in an entry-level physical therapy program: acceptance and cost. Journal of Physical Therapy Education. 1991;5(2):65-71. 13. DeAmicis PA. Interactive videodisc instruction as an alternative method of learning and performing a critical nursing skill. Comput Nurs. 1997;15:155-158. 14. Barker SP Comparison of effectiveness of interactive videodisc versus lecture- demonstration instruction. Phys Ther. 1988; 68:699-703.
15. Gutierras DJ. The Lesion Game(tm): a special communication. Phys Ther. 1989;69: 858-862.
16. Stephens PF, Doherty JA. The use of Apple Macintosh computers and Hypercard in teaching physiology laboratories. Am J Physiol 1992;263:S23-S28.
17. Shelledy DC. Computer-assisted instruction (CAI) in arterial blood gas interpretation, part I: the effect of CAI on students' ability to interpret blood gas values. Respiratory Care. February 1987:95-102. 18. Schmidt, SM, Arndt MJ, Gaston S, Miller BJ. The effectiveness of computer-managed instruction versus traditional classroom lecture on achievement outcomes. Comput Nurs. 1991;9:159-162.
19. Freeman A. Computer use in allied health programs. Journal of Learning Disabilities. 1987;20:206213.
20. Francis KT. Computer communication: model of skeletal muscle length/tension relationship. Phys Ther. 1985;65:238, 240, 242.
21. Whiteside MF, Whiteside JA. Preparing allied health faculty to use and develop com
puter-assisted instruction. J Allied Health. 1987;16:247-254.
22. Toth-Cohen S. Computer-assisted instruction as a learning resource for applied anatomy and kinesiology in the occupational therapy curriculum. Am J Occup Then 1995;49:821-827.
23. Culbert AJ, Cantelmo NL, Stafford ME, Allen DME. Interactive videodisc as an instructional tool in medical education. Methods Inf Med. 1989;28:357-359. 24. Guy J, Frisby A. Using interactive videodiscs to teach gross anatomy to undergraduates at Ohio State University. Acad Med. 1992;67:132-133.
25. Cutts JH III, Hazelwood S, Mitchell J, et al. GALE: a graphics-assisted learning environment for computer-assisted interactive videodisc education. Int J Biomed Comput. 1992;6:22-29.
26. Sanford MK, Hazelwood SE, Bridges AJ, et al. Effectiveness of computer-assisted interactive videodisc instruction in teaching rheumatology to physical and occupational therapy students. J Allied Health. 1996; 25:141-148.
27. Benedict SC, Coffield K. The effect of brain hemisphere dominance on learning by computer-assisted instruction and traditional lecture method. Comput Nurs. 1989;7: 152-156.
28. Modell H. Can technology replace live presentations in student laboratories? Am J Physiol 1989;256:S18-S20. 29. Jelovsek FR, Adebonojo L. Learning principles as applied to computer-assisted instruction. MD Comput. 1993;10:165-172. 30. Paulanka BJ. The learning characteristics of nursing students and computer assisted instruction. Comput Nurs. 1986;4:246-254. 31. Adams CC. Using a computer in teaching and testing therapeutic exercise concepts. Journal of Physical Therapy Education. 1987;1(1): 34-35.
32. Thompson EC. Computer-assisted instruction in curricula of physical therapist assistants. Phys Ther. 1987;67:1237-1239.
Brenda Boucher, PhD, PT, CHT
Diana Hunter, PhD, PT
Jason Henry, MSPT
Dr Boucher is Lecturer, Department of Physical Therapy, Southwest Texas State University, 601 University Dr, San Marcos, TX 78666. Address all correspondence to Dr Boucher. Dr Hunter is Associate Professor, Department of Physical Therapy, Southwest Texas State University. Mr Henry was a student in the physical therapy program at Southwest Texas State University at the time this study was conducted.…