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Teaching Human Anatomy before during and after COVID-19 Pandemic: A Longitudinal Study on Kinesiology Students' Performance, Cognitive Load, and Congruent Embodied Learning

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Title: Teaching Human Anatomy before during and after COVID-19 Pandemic: A Longitudinal Study on Kinesiology Students' Performance, Cognitive Load, and Congruent Embodied Learning
Language: English
Authors: Rawad Chaker, Mélanie Gallot, Ayodélé Madi, Christian Collet, Nady Hoyek (ORCID 0000-0003-1093-0263)
Source: Anatomical Sciences Education. 2025 18(1):48-58.
Availability: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
Peer Reviewed: Y
Page Count: 11
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Anatomy, Human Body, Kinesiology, Science Instruction, COVID-19, Pandemics, Electronic Learning, Blended Learning, In Person Learning, Science Achievement, Teaching Methods, Instructional Effectiveness, Difficulty Level, Cognitive Processes, Technology Integration, Computer Assisted Instruction
DOI: 10.1002/ase.2532
ISSN: 1935-9772
1935-9780
Abstract: During the COVID-19 pandemic, anatomy educators have demonstrated their ability to respond to face-to-face (F2F) teaching restrictions and offer emergency remote teaching and learning (ERTL) approach. Another educational model that was intensified during COVID-19 was blended learning (BL) which is a combination of F2F and online settings. Studies on the effects of the methods employed during COVID-19 pandemic on anatomy students' learning outcomes are sparse and show slightly similar but nuanced results. There is poor evidence on how the transition to online-only or to BL in response to COVID-19 impacted anatomy students' performance, cognitive load, and embodied learning. The main aim of this longitudinal study is to evaluate the effectiveness of ERTL and BL on anatomy performance in kinesiology students. The second aim of this study was to better understand students' performance in terms of cognitive load embodied learning, and the use of 3D digital tools. The results indicate no significant differences between F2F and ERTL students' performance. However, the results yielded significantly better performance for the BL students in comparison with both F2F (p = 0.001) and ERTL cohort (p = 0.001). The rapid transition to online-only teaching and learning neither enhanced nor deteriorated students' performance. The BL modality appears to be the most efficient. Learning outcomes were discussed in relation to cognitive load, embodied learning, and the use of 3D digital tools.
Abstractor: As Provided
Entry Date: 2024
Accession Number: EJ1454931
Database: ERIC
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  Value: <anid>AN0181847207;[8z8k]01jan.25;2024Dec27.02:24;v2.2.500</anid> <title id="AN0181847207-1">Teaching human anatomy before during and after COVID‐19 pandemic: A longitudinal study on kinesiology students' performance, cognitive load, and congruent embodied learning </title> <p>During the COVID‐19 pandemic, anatomy educators have demonstrated their ability to respond to face‐to‐face (F2F) teaching restrictions and offer emergency remote teaching and learning (ERTL) approach. Another educational model that was intensified during COVID‐19 was blended learning (BL) which is a combination of F2F and online settings. Studies on the effects of the methods employed during COVID‐19 pandemic on anatomy students' learning outcomes are sparse and show slightly similar but nuanced results. There is poor evidence on how the transition to online‐only or to BL in response to COVID‐19 impacted anatomy students' performance, cognitive load, and embodied learning. The main aim of this longitudinal study is to evaluate the effectiveness of ERTL and BL on anatomy performance in kinesiology students. The second aim of this study was to better understand students' performance in terms of cognitive load embodied learning, and the use of 3D digital tools. The results indicate no significant differences between F2F and ERTL students' performance. However, the results yielded significantly better performance for the BL students in comparison with both F2F (p = 0.001) and ERTL cohort (p = 0.001). The rapid transition to online‐only teaching and learning neither enhanced nor deteriorated students' performance. The BL modality appears to be the most efficient. Learning outcomes were discussed in relation to cognitive load, embodied learning, and the use of 3D digital tools.</p> <p>Keywords: anatomy; blended learning; cognitive load; Covid‐19; embodiment</p> <hd id="AN0181847207-2">INTRODUCTION</hd> <p></p> <hd id="AN0181847207-3">Emergency remote teaching and blended learning during the pandemic</hd> <p>By the end of 2019 and the beginning of 2020, the Coronavirus (COVID‐19) pandemic interrupted and impacted many dimensions of our lives, particularly higher education. Bozkurt et al.[<reflink idref="bib1" id="ref1">1</reflink>] proposed that the education implemented during the COVID‐19 pandemic should be categorized as emergency remote education. The main difference between emergency remote education and distance education is that the latter is an option while the former is an obligation. Blended learning (BL), which is a combination of face‐to‐face (F2F) and online settings, was exacerbated during COVID‐19.[<reflink idref="bib2" id="ref2">2</reflink>] BL has existed for over a decade and is believed to be one of the most used methods in education to promote active learning engagement, flexible learning experiences, and enhance students' learning outcomes.[<reflink idref="bib2" id="ref3">2</reflink>] Several systematic reviews on the impact of BL in higher education have been conducted with the aim of identifying its benefits, challenges, and its most appropriate design principles.[<reflink idref="bib2" id="ref4">2</reflink>], [<reflink idref="bib3" id="ref5">3</reflink>], [<reflink idref="bib4" id="ref6">4</reflink>], [<reflink idref="bib5" id="ref7">5</reflink>]</p> <p>Anatomy educators have demonstrated their eagerness to challenge and innovate their pedagogical approaches as demonstrated by the number and quality of published articles across many journals particularly Anatomical Sciences Education.[<reflink idref="bib6" id="ref8">6</reflink>] Indeed, this increase in publications has never been more evident than during the COVID‐19 pandemic, where committed anatomy educators have swiftly demonstrated their ability to adapt their learning and teaching approaches to respond to F2F teaching restrictions and offer an effective emergency remote teaching and learning (ERTL) approach.[<reflink idref="bib7" id="ref9">7</reflink>], [<reflink idref="bib8" id="ref10">8</reflink>], [<reflink idref="bib9" id="ref11">9</reflink>], [<reflink idref="bib10" id="ref12">10</reflink>], [<reflink idref="bib11" id="ref13">11</reflink>] However, the widespread adoption of digital technologies affected F2F lectures after the pandemic: educators lectures in empty lecture halls, with students choosing not to re‐engage with the F2F lecture and instead engaging with the recorded online lecture asynchronously.[<reflink idref="bib12" id="ref14">12</reflink>] According to Evans[<reflink idref="bib10" id="ref15">10</reflink>], if anatomy lecture is to survive, whether delivered F2F or online, a pedagogical shift is required.</p> <hd id="AN0181847207-4">The impact of going online during the pandemic on anatomy students' learning outcomes</hd> <p>Anatomy educators[[<reflink idref="bib13" id="ref16">13</reflink>]] emphasize the need for deeper evaluations of teaching methods and their impact on learning outcomes to fully understand the benefits realized during the pandemic. Studies on the impact of COVID‐19 teaching methods on anatomy students' learning outcomes are limited and show nuanced results.</p> <p>Wilhelm et al.[<reflink idref="bib15" id="ref17">15</reflink>] compared pre‐pandemic F2F learning with emergency remote teaching and learning (ERTL) during the pandemic. They observed improved examination grades during ERTL despite lower student confidence and engagement. This improvement is attributed to: (i) new grading practices; (ii) two exam attempts instead of one in F2F; (iii) a shift to multiple‐choice questions; and (iv) unproctored exams during the pandemic.</p> <p>Nathaniel et al.[<reflink idref="bib16" id="ref18">16</reflink>] found different results when comparing 2019 F2F learning with the 2020 BL approach. Overall student performance did not differ significantly, except in one objective—identify and correlate clinical gross anatomical features using common analytic and imaging modalities—where F2F students performed better. This was likely due to the importance of small Group F2F clinical case discussions (not allowed during the pandemic). Interestingly, the 2020 cohort had more low‐performing students. The 2019 cohort had more average‐performing students. Both years had an equal number of high performers. The study concluded that the BL approach was effective for high‐performing medical students.</p> <p>Diong et al.[<reflink idref="bib17" id="ref19">17</reflink>] found similar results when comparing F2F and online anatomy learning for undergraduate and postgraduate students. Online learning during the pandemic decreased undergraduate performance but improved postgraduate results. The authors concluded that different learning modes suit different student types. Undergraduates may need more structured learning, hands‐on functional anatomy demonstrations using human body specimens, and a social learning context. Conversely, postgraduates likely benefit from their life experiences, which makes them more adept at independent learning.</p> <p>Finally, Yun et al.[<reflink idref="bib18" id="ref20">18</reflink>] provided evidence that examination scores significantly decreased in 2020 compared with 2019 except for the trunk anatomy session during which students scored significantly higher in 2020. According to the authors, only professors in charge of the trunk session used a three‐dimensional (3D) digital anatomy educational software. Yun et al.[<reflink idref="bib18" id="ref21">18</reflink>] concluded that an adequate integration of 3D digital applications within a BL program including F2F anatomy laboratories can potentially improve academic achievement.</p> <hd id="AN0181847207-5">Anatomy online learning: The need to embody the learning process</hd> <p>Quantitative studies on students' learning outcomes suggest that online anatomy learning and BL are beneficial for a certain type of students, namely, older students with more life experience[<reflink idref="bib17" id="ref22">17</reflink>] and high‐performing students.[<reflink idref="bib16" id="ref23">16</reflink>] It is believed that those students probably have stronger self‐regulation skills needed to succeed in online and BL.[[<reflink idref="bib2" id="ref24">2</reflink>], [<reflink idref="bib5" id="ref25">5</reflink>]] Online anatomy learning and BL effectiveness depend as well on the constructive alignment between the teaching and learning activities and the type and format of assessment tasks.[[<reflink idref="bib11" id="ref26">11</reflink>], [<reflink idref="bib15" id="ref27">15</reflink>]] In other words, assessment modalities should be chosen to best evaluate the skills students are expected to achieve through anatomy learning.[<reflink idref="bib11" id="ref28">11</reflink>] Knowing that anatomy is taught in different curricula including clinical (e.g., medicine, physiotherapy or osteopathy) and sports sciences courses (e.g., kinesiology), the skills students are expected to achieve are not the same. Thus, online anatomy learning and BL effectiveness, threats, and opportunities depend on the curriculum. For instance, in medical studies reproducing the physical and tactile‐based experiences that characterize traditional F2F human specimen dissection courses, is not possible or ideal in an online environment.[<reflink idref="bib9" id="ref29">9</reflink>] Conversely, in the French kinesiology bachelor program, only functional anatomy of the musculoskeletal system is taught, without dissection or prosection courses.[<reflink idref="bib19" id="ref30">19</reflink>] There is a large body of evidence that understanding functional anatomy requires: (i) good spatial and motor imagery abilities (e.g., Ref. [[<reflink idref="bib20" id="ref31">20</reflink>]]); (ii) the use of 3D tools (e.g., Ref. [[<reflink idref="bib21" id="ref32">21</reflink>]]), and (iii) learning in motion or embodied learning[<reflink idref="bib19" id="ref33">19</reflink>] (e.g., Ref. [[<reflink idref="bib22" id="ref34">22</reflink>]]). Interestingly, these three requirements are interdependent and exert direct effects on students' cognitive load.[<reflink idref="bib23" id="ref35">23</reflink>], [<reflink idref="bib24" id="ref36">24</reflink>], [<reflink idref="bib25" id="ref37">25</reflink>] Furthermore, it is believed that embodied learning, through gestures enactment during problem‐solving, reduces learner's cognitive load.[[<reflink idref="bib26" id="ref38">26</reflink>]] Furthermore, Johnson‐Glenberg and Megowan‐Romanowicz[<reflink idref="bib28" id="ref39">28</reflink>] demonstrated that learning outcomes are sensitive to the level of embodiment (low vs. high) and that gestures need to be congruent with the learning task to increase the amount of sensorimotor engagement. This is particularly relevant for learning functional anatomy as the knowledge to acquire is the movement analysis itself.[<reflink idref="bib19" id="ref40">19</reflink>]</p> <hd id="AN0181847207-6">Aim of the study</hd> <p>Knowing that cognitive load may also be reduced by providing students with remotely accessible resources,[<reflink idref="bib29" id="ref41">29</reflink>] there is poor evidence on how the transition to online‐only or to BL in response to COVID‐19 impacted anatomy students' cognitive load and performance. Furthermore, there is no existing evidence on how embodied learning impacted students' learning outcomes during the rapid transition due to the pandemic. The first aim of this longitudinal study is to evaluate the effectiveness of ERTL (i.e. online‐only) and BL on anatomy performance in kinesiology students. This was achieved by comparing the ERTL (2020) and the BL (2021) cohorts' academic performances with previous academic years (F2F only). During the ERTL condition (the 2020 cohort), students were expected to perform like in previous years, for example, without any decrease in performance (H1). Conversely, students enrolled in the BL condition (the 2021 cohort) were expected to perform significantly better than all other previous cohorts (H2). The second aim was to better understand students' performance in terms of cognitive load, embodied learning, and the use of 3D digital tools. Hence, higher embodiment conditions foster better learning thanks to a lower induced cognitive load (H3).</p> <hd id="AN0181847207-7">MATERIALS AND METHODS</hd> <p></p> <hd id="AN0181847207-8">Synopsis of examined course</hd> <p>The general framework of the examined course in its mode prior to COVID‐19 has been previously published.[[<reflink idref="bib19" id="ref42">19</reflink>], [<reflink idref="bib21" id="ref43">21</reflink>], [<reflink idref="bib30" id="ref44">30</reflink>]] It is a 6 ECTS (European Credit Transfer and Accumulation System) course on the functional anatomy of the musculoskeletal system delivered during the first‐year kinesiology bachelor program at Claude‐Bernard Lyon 1 University, France. The course consists of 12 lecture sessions and 12 practical sessions, each lasting 2 h. There was no dissection or prosection during these courses. Half of the program, consisting of 6 lectures and 6 practical sessions on the trunk musculoskeletal system and upper and lower limb osteology, is delivered in the first semester. The remaining half, also comprising 6 lectures and 6 practical sessions, focuses on lower and upper limb arthrology and myology and is delivered in the second semester. The data analyzed in this study were collected from cohorts of students attending the second semester. All participants, spanning across all cohorts (2018, 2019, ERTL and BL) were provided with identical written reference materials (lecture notes and practical session exercises) as study guidelines. Moreover, they were given unrestricted access to 3D animations, whose efficacy had been previously demonstrated.[<reflink idref="bib21" id="ref45">21</reflink>]</p> <p>Before COVID‐19 pandemic (2018 and 2019), during F2F lecture sessions, the lecturer delivered the content in a one‐way method of communication by commenting on the university's above‐mentioned 3D animations. To engage learners' active participation, a 2‐min session for questions every 15 min was planned. The practical F2F sessions consisted of problem‐based learning and team‐based learning exercises during which the students were encouraged to execute movement before solving functional anatomy problems.</p> <p>During the second semester of 2019–2020 academic year, the university closed and all courses were delivered online only. During this ERTL experience with the 2020 cohort, rather than using long‐recorded lectures, and in line with recommendations from the literature,[[<reflink idref="bib9" id="ref46">9</reflink>]] the lecturer created sets of mini‐lectures by recording short videos of 5–8 min each. He used the above‐mentioned 3D animations to record the mini‐lectures by adding voice‐over commentaries. All new videos were uploaded to the university learning management system for asynchronous viewing by the students. Furthermore, during the scheduled time for lectures and practical sessions online synchronous classes were delivered using Cisco Webex Meetings® (Version 41.3.1). During online lectures, the lecturer focused on the main concepts and themes of a topic that had already been covered in the short videos. The practice of dedicating a 2‐min session for questions every 15 min was seamlessly maintained using the online chat tool. During online practical sessions, the same problem‐based‐learning and team‐based learning exercises were transitioned.</p> <p>During the second semester of 2020–2021 academic year, restrictions regarding COVID‐19 changed in France. Students were allowed to come back to campus. However, to better respect social distancing, a BL modality was implemented. This enabled, every other week, half of the cohort to physically attend a lecture and a practical session while the other half attended it synchronously online. The following week students who were online came to the campus and vice‐versa. During this BL session (the 2021 cohort) students benefited from the same sets of mini‐lectures created the previous year. Three main changes were implemented for the BL cohort. First, all online activities were redesigned. Instead of using the university learning management system as a video and document depository, new learning objects were created, such as forums, wikis and mini‐quiz. This re‐design aimed at maintaining as much active engagement as possible and aligns well with established multimedia learning theories.[<reflink idref="bib25" id="ref47">25</reflink>] Second, lectures were replaced by flipped blended classrooms. Prior to attending the flipped blended classroom, students were required to learn key anatomy concepts via the pre‐recorded mini‐lectures and the above‐mentioned new learning objects designed in the learning management system. During the flipped blended classroom, the lecturer started by using a case study (e.g., functional analysis of a specific sport movement; a sports injury analysis; etc.) to engage dynamic interactive discussion with the students. On‐site students were given the opportunity to interact directly with the lecturer, either by commenting on the case study or by requesting further explanations and details about topics already covered in the short videos. The entire flipped blended classroom was broadcast on YouTube Live using a Mevo camera®. Half of the cohort, comprising online students, were afforded the opportunity to actively engage with the lecturer through the interactive YouTube Live Chat feature. To enhance student engagement and peer support, a student on‐site volunteered to orally present a selection of the written questions in the live chat. Third, the online practical sessions using the same problem‐based‐learning and team‐based learning exercises were delivered synchronously both on‐site and online using Cisco Webex Meetings® (Version 41.3.1). The above‐described BL synopsis has been filmed by the university's department of pedagogical innovation and is available here: https://youtu.be/3ocXwp2xULQ?si=xbD5Zu8rx_8aTTeW.</p> <hd id="AN0181847207-9">Student performance assessment</hd> <p>To explore changes in students' performance due to ERTL and BL, the grades from the final summative assessments were compared. The alignment between the assessments and the learning goals was systematically verified according to the Bloom's Taxonomy of Learning Objectives.[<reflink idref="bib31" id="ref48">31</reflink>] Assessments contained different questions across academic years. However, items were randomly extracted from the same bank of questions and had the same difficulty level. Questions corresponded to the first four categories of Bloom's taxonomy (knowledge, comprehension, application, and analysis). Items were MCQs with three possible answers: true, false, or "I do not know." Only correct answers were kept for each test. One score, ranging from 0 to 20, was collected for each student. An example of the functional anatomy questions has been previously published.[[<reflink idref="bib19" id="ref49">19</reflink>], [<reflink idref="bib30" id="ref50">30</reflink>]]</p> <p>Before the pandemic, the summative assessments consisted of paper and pencil tests containing 100 MCQs. One hour was given to answer 100 MCQs. Assessments were administered at the end of the semester during specific proctored assessment sessions. During ERTL, a rapid transition to online MCQs was implemented. However, to maintain quality, access, and assurance requirements,[<reflink idref="bib9" id="ref51">9</reflink>] a rigorous methodology was followed to transition from paper and pencil to online MCQs. First, the entire MCQs bank was transferred to the assessment platform of the university's learning management system. Items were randomly extracted by the platform and scores were automatically calculated following the same marking scheme. Second, all items were double‐checked by two anatomy experts for (i) anatomically inaccurate or wrong items; (ii) grammar and spelling mistakes; (iii) errors in the items' settings and marking scheme. Third, before the official final examination, the entire cohort of students was invited to pre‐test the online MCQs.</p> <p>The primary aim of this pre‐test was to meticulously identify and rectify any potential computing bugs within the assessment platform and to meticulously scrutinize the items for any errors or discrepancies. The pre‐test lasted 1 h and was open for synchronous participation only. Sixty students volunteered to take part in this pre‐test. Following the pre‐test, volunteers were asked to give written feedback on their experience by answering the following questions: "have you encountered any computing bug?"; "have you identified any items that may contain unclear or ambiguous turns of phrase?"; "have you detected any item containing grammar and/or spelling mistakes?"; "do you think that one hour is too long/too short/enough to answer 100 online MCQs?" Some computing bugs were detected and corrected afterwards.</p> <p>The predominant feedback indicates that a significant number of students found the 1‐h duration excessive for completing the test. They noted that selecting the correct answers digitally required less time compared with filling out a paper sheet with a pencil. Following this last feedback, times (in ms) spent to answer every single question were extracted from the assessment platform in order to estimate the mean time needed to answer 100 online MCQs. The mean time needed to complete the pre‐test was around 45 min.</p> <p>The official summative assessment took place, 2 weeks later, during a synchronous session. An information email was sent to all students. It contained the following information: assessment date, time, duration, and marking scheme; the URL for accessing instructions using one's institutional username and password; and the administrator's email address for any issues related to bugs or connection problems during the session. The administrator initiated the online assessment session precisely at the scheduled date and time, and after a duration of 45 min, duly concluded it. All scores were automatically calculated and were available, immediately after the assessment, for the administrator and educators only. A score ranging from 0 to 20 was collected for each student. No computing bugs or connection problems were detected. No requests were sent by email to the session administrator. The only concern regarding this synchronous online assessment is that it was not proctored. Even though students used their personal institutional username and password for identification, we are not sure whether they cheated or not. This issue was recognized as a growing issue by many colleagues during the pandemic.[<reflink idref="bib9" id="ref52">9</reflink>]</p> <p>The following year, for the 2021 cohort enrolled in the BL modality, the same online assessment was administered. However, it was proctored and took place at the end of the semester in the university's lecture halls.</p> <p>In sum, in order to explore changes in students' performance across academic years, authors compared 523, 590, 593, and 591 summative assessment scores of the 2018 (before COVID‐19), 2019 (before COVID‐19), 2020 (ERTL), and 2021 (BL), respectively.</p> <hd id="AN0181847207-10">Post‐course survey</hd> <p>Student strategies and perception of the learning setting during both the ERTL and BL modalities were assessed by administering a post‐course survey. The survey intended to document students' perceptions and estimations regarding: (i) their strategies when studying online; (ii) their strategies when answering the online assessments; (iii) the recorded mini‐lectures. This survey was designed by the authors and created using Google Form. It was pretested by two anatomy teachers, and distributed via email to all students enrolled in the 2020 and 2021 courses. The survey was available from the end of April until the end of July 2020 and 2021, respectively. Students were not offered extra credit for its completion. The survey consisted of 12 questions.</p> <p>Questions 1–5 assessed students' strategies related to embodied learning when studying online. For instance, they were asked whether they enacted movements when studying functional anatomy and whether the enacted movements were congruent with the movement analysis itself (see Refs. [[<reflink idref="bib19" id="ref53">19</reflink>], [<reflink idref="bib28" id="ref54">28</reflink>]] for embodiment levels). Questions 6–9 assessed students' strategies when answering the online assessments with similar questions related to the embodiment and congruency of the enacted movement. Questions 10–12 assessed students' perception of how the mini‐lectures allowed them to better understand anatomical concepts and whether they were as effective as traditional face‐to‐face lectures.</p> <p>A seven‐point Likert scale (1 = strongly disagree, 2 = disagree, 3 = somewhat disagree, 4 = neither agree nor disagree, 5 = somewhat agree, 6 = agree, and 7 = strongly agree) was used. The survey received 369 and 326 responses from the ERTL and BL cohorts, respectively. Response rates were 62.22% for 2020 (ERTL) and 55.16% for 2021 (BL), respectively.</p> <hd id="AN0181847207-11">Student cognitive load</hd> <p>After completing the post‐course survey students were asked to complete an online version of the NASA‐Task Load Index (TLX).[<reflink idref="bib32" id="ref55">32</reflink>] The NASA‐TLX evaluated the load associated with the online assessment. It rated the contribution of the following six factors to the online assessment workload: (<reflink idref="bib1" id="ref56">1</reflink>) mental demand, (<reflink idref="bib2" id="ref57">2</reflink>) physical demand, (<reflink idref="bib3" id="ref58">3</reflink>) temporal demand, (<reflink idref="bib4" id="ref59">4</reflink>) performance, (<reflink idref="bib5" id="ref60">5</reflink>) overall effort, and (<reflink idref="bib6" id="ref61">6</reflink>) frustration. Each item provided information about the nature of the workload induced by the online assessment. The NASA‐TLX is considered a valid tool to assess the mental workload in the medical field.[<reflink idref="bib33" id="ref62">33</reflink>] The NASA‐TLX received 93 and 56 responses from the ERTL and BL cohorts, respectively.</p> <p>Table 1 summarizes the overall course synopsis, modalities, and data collected from all cohorts before COVID‐19, ERTL, and BL.</p> <p>1 TABLE Course synopsis, modalities, and data collected from all cohorts before COVID‐19, ERTL, and BL.</p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="left" /><th align="left">F2F (before COVID‐19)</th><th align="left">ERTL (2020)</th><th align="left">BL (2021)</th></tr></thead><tbody valign="top"><tr><td align="left">Modality</td><td align="left">F2F only</td><td align="left">Online only</td><td align="left">BL with synchronous and asynchronous online activities</td></tr><tr><td align="left">Anatomy program</td><td align="left">Same</td></tr><tr><td align="left">Anatomy educators</td><td align="left">Same</td></tr><tr><td align="left">Lectures modalities and content</td><td align="left">F2F only: lecturer commenting 3D animations</td><td align="left">Online only + recorded mini‐lectures using 3D animations</td><td align="left">Flipped Blended Lectures (½ cohort F2F; ½ cohort online) + same recorded mini‐lectures</td></tr><tr><td align="left">Practical sessions modalities and content</td><td align="left">F2F only: problem‐based and team‐based learning exercises</td><td align="left">Online: same content</td><td align="left">BL (½ cohort F2F; ½ cohort online): same content</td></tr><tr><td align="left">Reference material and study guidelines</td><td align="left">Same</td></tr><tr><td align="left">Learning management system use</td><td align="left">Video and document depository</td><td align="left">Video and document depository</td><td align="left">Video and document depository + forums + wikis + mini‐quiz</td></tr><tr><td align="left">Summative assessments</td><td align="left">Paper and pencil proctored MCQs</td><td align="left">Online non‐proctored MCQs</td><td align="left">Online proctored MCQs</td></tr><tr><td align="left">Data collected</td><td align="left">Summative assessments</td><td align="left">Summative assessments + Post‐course survey + Cognitive Load</td><td align="left">Summative assessments + Post‐course survey + Cognitive Load</td></tr></tbody></table> </ephtml> </p> <hd id="AN0181847207-12">Participants and ethics</hd> <p>Anatomy grades and data from the post‐course survey and the NASA‐TLX were collected from first‐year kinesiology students at Claude‐Bernard Lyon 1 University, France. Students who were repeating the first year were excluded from the data collection. This was an observational behavioral study with no interventional components, meaning no intrusive procedures or ingestion of active molecules. In line with the Helsinki declaration and the French ethical law, all participants were asked for consent prior to data collection (post‐course survey and NASA‐TLX) and were informed that the survey was voluntary anonymous. Students were informed that all data were to be used for research purposes. To ensure privacy, IP addresses were not linked with completed surveys. The results were thus analyzed anonymously.</p> <hd id="AN0181847207-13">Data analysis</hd> <p>To compare the ERTL (2020) and the BL (2021) cohorts' academic performances with two previous academic years (F2F only in 2018 and 2019), independent <emph>t</emph>‐tests were run for two different reasons: (i) only raw data were available for the 2018 and 2019 cohorts (number of participants, means, and standard deviations); (ii) these tests allow to directly identify between which pairs potential significant differences are observed.</p> <p>For NASA‐TLX, ratings for each dimension were collected using 20‐step bipolar scales administered online, with scores ranging from 0 to 100. Following this, the NASA‐TLX score was computed by multiplying the rating of each dimension by its respective weight. Finally, the overall workload was derived by summing the weighted scores across dimensions and dividing by 15.[<reflink idref="bib32" id="ref63">32</reflink>]</p> <p>Multiple regression linear analyses using the backward deletion method[<reflink idref="bib34" id="ref64">34</reflink>] were used for ERTL and BL cohorts in order to understand the interaction between students' performance and both post‐course survey items and the NASA‐TLX dimensions. With the backward deletion method, the selection analysis starts with a model that contains all potentially relevant independent variables, which are removed until obtaining the best‐predicted model.</p> <p>Cronbach's <emph>α</emph> was used to measure the internal consistency of the students' performance assessment and the post‐course survey items using Likert scales.</p> <hd id="AN0181847207-14">RESULTS</hd> <p>Descriptive results indicate moderate to high levels of embodiment factors (Table 2). Overall, ERTL and BL cohorts display moderate to high levels from <emph>M</emph> = 4.67 (<emph>SD</emph> = 1.61) to <emph>M</emph> = 5.39 (<emph>SD</emph> = 1.50), for embodiment while studying. They also display moderate to high levels from <emph>M</emph> = 3.55 (<emph>SD</emph> = 1.98) to <emph>M</emph> = 4.83 (<emph>SD</emph> = 1.82), for embodiment while taking the final assessment. Students are overall highly satisfied concerning the 3D video mini‐lectures (<emph>M</emph> = 4.69; <emph>SD</emph> = 1.92), and they feel they efficiently helped them understand functional anatomy notions (<emph>M</emph> = 5.63; <emph>SD</emph> = 1.63).</p> <p>2 TABLE Post‐course survey and NASA‐TLX descriptive results (M and SD) of ERTL and BL cohorts.</p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="left">Measures</th><th align="left">ERTL (2020)</th><th align="left">BL (2021)</th><th align="left">Full sample</th></tr><tr><th align="left"><italic>M</italic></th><th align="left"><italic>SD</italic></th><th align="left"><italic>M</italic></th><th align="left"><italic>SD</italic></th><th align="left"><italic>M</italic></th><th align="left"><italic>SD</italic></th></tr></thead><tbody valign="top"><tr><td align="left">Embodiment while studying</td></tr><tr><td align="left">I enacted movements</td><td align="char" char=".">5.04</td><td align="char" char=".">1.73</td><td align="char" char=".">5.74</td><td align="char" char=".">1.27</td><td align="char" char=".">5.39</td><td align="char" char=".">1.50</td></tr><tr><td align="left">I enacted movements while focusing on body segments</td><td align="char" char=".">4.40</td><td align="char" char=".">1.71</td><td align="char" char=".">4.93</td><td align="char" char=".">1.5</td><td align="char" char=".">4.67</td><td align="char" char=".">1.61</td></tr><tr><td align="left">I left the seated position to enact movements</td><td align="char" char=".">4.86</td><td align="char" char=".">1.97</td><td align="char" char=".">5.24</td><td align="char" char=".">1.65</td><td align="char" char=".">5.05</td><td align="char" char=".">1.81</td></tr><tr><td align="left">I left the seated position to enact movements while focusing on body segments</td><td align="char" char=".">4.11</td><td align="char" char=".">1.84</td><td align="char" char=".">4.80</td><td align="char" char=".">1.72</td><td align="char" char=".">4.46</td><td align="char" char=".">1.78</td></tr><tr><td align="left">I modified my knowledge because enacted and/or observed my own body movements</td><td align="char" char=".">4.34</td><td align="char" char=".">1.90</td><td align="char" char=".">5.00</td><td align="char" char=".">1.51</td><td align="char" char=".">4.67</td><td align="char" char=".">1.71</td></tr><tr><td align="left">Embodiment while taking final assessment</td></tr><tr><td align="left">I enacted movements</td><td align="char" char=".">4.69</td><td align="char" char=".">1.89</td><td align="char" char=".">4.96</td><td align="char" char=".">1.75</td><td align="char" char=".">4.83</td><td align="char" char=".">1.82</td></tr><tr><td align="left">I enacted movements while focusing on body segments</td><td align="char" char=".">4.21</td><td align="char" char=".">1.75</td><td align="char" char=".">4.56</td><td align="char" char=".">1.76</td><td align="char" char=".">4.39</td><td align="char" char=".">1.76</td></tr><tr><td align="left">I left the seated position to enact movements</td><td align="char" char=".">3.83</td><td align="char" char=".">2.27</td><td align="char" char=".">4.11</td><td align="char" char=".">2.14</td><td align="char" char=".">3.97</td><td align="char" char=".">2.21</td></tr><tr><td align="left">I left the seated position to enact movements while focusing on body segments</td><td align="char" char=".">3.34</td><td align="char" char=".">1.97</td><td align="char" char=".">3.75</td><td align="char" char=".">1.98</td><td align="char" char=".">3.55</td><td align="char" char=".">1.98</td></tr><tr><td align="left">Mini‐lectures</td></tr><tr><td align="left">I visualized all the 3D videos with attention</td><td align="char" char=".">4.60</td><td align="char" char=".">2.05</td><td align="char" char=".">5.80</td><td align="char" char=".">1.56</td><td align="char" char=".">5.20</td><td align="char" char=".">1.81</td></tr><tr><td align="left">They allowed me to better understand some notions of movement functional anatomy</td><td align="char" char=".">5.12</td><td align="char" char=".">1.83</td><td align="char" char=".">6.13</td><td align="char" char=".">1.22</td><td align="char" char=".">5.63</td><td align="char" char=".">1.53</td></tr><tr><td align="left">They are as efficient as face‐to‐face lectures</td><td align="char" char=".">4.00</td><td align="char" char=".">2.01</td><td align="char" char=".">5.37</td><td align="char" char=".">1.83</td><td align="char" char=".">4.69</td><td align="char" char=".">1.92</td></tr><tr><td align="left">NASA‐TLX<xref ref-type="fn" rid="tfn1" /></td></tr><tr><td align="left">Mental demand</td><td align="char" char=".">81.40</td><td align="char" char=".">12.81</td><td align="char" char=".">82.68</td><td align="char" char=".">13.27</td><td align="char" char=".">82.04</td><td align="char" char=".">13.04</td></tr><tr><td align="left">Physical demand</td><td align="char" char=".">53.33</td><td align="char" char=".">23.08</td><td align="char" char=".">48.48</td><td align="char" char=".">26.47</td><td align="char" char=".">50.905</td><td align="char" char=".">24.77</td></tr><tr><td align="left">Temporal demand</td><td align="char" char=".">87.15</td><td align="char" char=".">17.09</td><td align="char" char=".">81.61</td><td align="char" char=".">20.22</td><td align="char" char=".">84.38</td><td align="char" char=".">18.65</td></tr><tr><td align="left">Performance</td><td align="char" char=".">53.28</td><td align="char" char=".">20.55</td><td align="char" char=".">50.00</td><td align="char" char=".">23.89</td><td align="char" char=".">51.64</td><td align="char" char=".">22.22</td></tr><tr><td align="left">Effort</td><td align="char" char=".">77.10</td><td align="char" char=".">14.71</td><td align="char" char=".">79.46</td><td align="char" char=".">15.97</td><td align="char" char=".">78.28</td><td align="char" char=".">15.34</td></tr><tr><td align="left">Frustration</td><td align="char" char=".">61.94</td><td align="char" char=".">22.87</td><td align="char" char=".">58.30</td><td align="char" char=".">29.42</td><td align="char" char=".">60.12</td><td align="char" char=".">26.14</td></tr><tr><td align="left">Overall</td><td align="char" char=".">27.61</td><td align="char" char=".">7.41</td><td align="char" char=".">26.70</td><td align="char" char=".">8.62</td><td align="char" char=".">27.16</td><td align="char" char=".">8.01</td></tr></tbody></table> </ephtml> </p> <p>1 a All values are weighted, as per the NASA‐TLX standard procedure.</p> <hd id="AN0181847207-15">Validity and reliability of students' performance assessment and post‐course survey tool</hd> <p>Student's performance assessment validity has been previously published.[[<reflink idref="bib19" id="ref65">19</reflink>], [<reflink idref="bib30" id="ref66">30</reflink>]] Assessment items were randomly extracted from a bank of questions with a level of internal consistency (Cronbach's <emph>α</emph>) ranging from 0.78 up to 0.96. The post‐course survey was internally consistent. Cronbach's <emph>α</emph> analysis revealed that questions of the post‐course survey were reliable and internally consistent (Cronbach's <emph>α</emph> = 0.84 for items on students' strategies when studying online; Cronbach's <emph>α</emph> = 0.79 for items on students' strategies when answering the online assessments; Cronbach's <emph>α</emph> = 0.87 for items on students' perception of the recorded mini‐lectures efficiency).</p> <hd id="AN0181847207-16">Student's performance</hd> <p>To verify H1 (the ERTL cohort performs like previous years, for example, without any decrease in performance), we need to verify first if two pre‐COVID‐19 cohorts of students in a standard on‐campus learning setting performed similarly, and then compare the ERTL setting with both cohorts. Independent <emph>t</emph>‐tests between the academic performances of the 2018 cohort (<emph>N</emph> = 523; <emph>M</emph> = 8.05; <emph>SD</emph> = 5.52) and those of the 2019 cohort (<emph>N</emph> = 590; <emph>M</emph> = 7.81; <emph>SD</emph> = 4.14), yield no significant differences: <emph>t</emph> = −0.82; <emph>p</emph> = 0.409. Then, we compared the 2020 ERTL condition (<emph>N</emph> = 593; <emph>M</emph> = 7.73; <emph>SD</emph> = 4.27) with both pre‐COVID‐19 conditions. The results indicate no significant differences, respectively: <emph>t</emph> = −1.09; <emph>p</emph> = 0.276 and <emph>t</emph> = −0.32; <emph>p</emph> = 0.744. Hence, we accept H1: students who benefited from the ERTL setting performed equally to those of the F2F learning setting of the two previous years.</p> <p>To verify H2 (the BL cohort performs significantly better than all other previous cohorts), we ran independent <emph>t</emph>‐tests between the BL condition, that is, promotion 2021 (<emph>N</emph> = 591; <emph>M</emph> = 9.12; <emph>SD</emph> = 4.66), and both ERTL and on‐campus conditions. The results yielded significantly better performance for the BL with moderate size effects in comparison with all previous conditions: <emph>t</emph> = 1.07; <emph>p</emph> = 0.001; <emph>d</emph> = 0.21 (with 2018 F2F cohort), <emph>t</emph> = 5.10; <emph>p</emph> = 0.001; <emph>d</emph> = 0.29 (with 2019 F2F cohort) and <emph>t</emph> = 5.35; <emph>p</emph> = 0.001; <emph>d</emph> = 0.311 (with ERTL cohort). Hence, we accept H2: the BL cohort performed better than both F2F and ERTL cohorts.</p> <p>Table 3 and Figure 1 show academic performance at summative assessments for all cohorts.</p> <p>3 TABLE Number of students (N) and academic performance at summative assessment (means and standard deviation) per cohort.</p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="left">Cohort</th><th align="left"><italic>N</italic></th><th align="left"><italic>M</italic></th><th align="left"><italic>SD</italic></th></tr></thead><tbody valign="top"><tr><td align="left">2018 (F2F)</td><td align="char" char=".">523</td><td align="char" char=".">8.05</td><td align="char" char=".">5.52</td></tr><tr><td align="left">2019 (F2F)</td><td align="char" char=".">590</td><td align="char" char=".">7.81</td><td align="char" char=".">4.14</td></tr><tr><td align="left">2020 (ERT)</td><td align="char" char=".">593</td><td align="char" char=".">7.73</td><td align="char" char=".">4.27</td></tr><tr><td align="left">2021 (BL)</td><td align="char" char=".">591</td><td align="char" char=".">9.12</td><td align="char" char=".">4.66</td></tr></tbody></table> </ephtml> </p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/8Z8K/01jan25/ase2532-fig-0001.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="ase2532-fig-0001.jpg" title="1 Students performances on summative assessments. 2018 and 2019: F2F; ***p = 0.001." /> </p> <p></p> <hd id="AN0181847207-18">Interaction between students' performance, survey items, and perceived workload</hd> <p>To verify H3 (higher embodiment conditions foster better learning thanks to a lower induced cognitive load), we ran two linear regression analyses with backward deletion method, fixing either ERTL or BL final assessment scores as predicted variables (see Table 2). We note that we used the subscales of the NASA‐TLX separately, rather than the total workload score, in order to examine in detail which ones contribute significantly to performance.</p> <hd id="AN0181847207-19">ERTL cohort</hd> <p>The variance inflation factor test result is acceptable for all the dependent variables (1.114 < VIF < 1.247), which verifies the assumption of non‐multicollinearity. Results yielded a model predicting <emph>R</emph><sups>2</sups> = 20.30% of ERTL final assessment total variance. In terms of workload, Frustration (<emph>β</emph> = −0.203; <emph>p</emph> = 0.045) participates significantly in the model. Additionally, mini‐lectures' visualization also predict significantly ERTL final assessment score: <emph>β</emph> = 0.250; <emph>p</emph> = 0.013. Finally, two embodiment factors also predict ERTL final assessment score: congruent embodiment while studying (i.e., enacting and focusing on body segments while studying) and embodiment during final assessment (i.e., enacting while taking of final assessment without focus on congruency): <emph>β</emph> = 0.274; <emph>p</emph> = 0.010 and <emph>β</emph> = −0.282; <emph>p</emph> = 0.007, respectively.</p> <hd id="AN0181847207-20">BL cohort</hd> <p>The variance inflation factor test result is acceptable for all the dependent variables (1.013 < VIF <1.057), which verifies the assumption of non‐multicollinearity. Results yielded a model predicting <emph>R</emph><sups>2</sups> = 32.40% of BL final assessment total variance. Workload factors, that is, temporal demand (<emph>β</emph> = −0.270; <emph>p</emph> = 0.021) and performance (<emph>β</emph> = −0.362; <emph>p</emph> = 0.003) participate significantly to the model. Additionally, one embodiment factor also predicts BL's final assessment score: congruent embodiment during final assessment (i.e., enacting and focusing on body segments while taking of final assessment): <emph>β</emph> = 0.309; <emph>p</emph> = 0.008.</p> <p>These results confirm H3: higher embodiment conditions foster better learning thanks to reduced cognitive load. Table 4 shows the ERTL and BL cohorts' regressions analyses.</p> <p>4 TABLE ERTL and BL cohorts' regression analyses with significant factors.</p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="left" /><th align="left">Unstandardized coefficients</th><th align="left">Coefficients</th><th align="left"><italic>t</italic></th><th align="left"><italic>p</italic></th><th align="left">Collinearity statistics</th></tr><tr><th align="left">Estimate</th><th align="left"><italic>SE</italic></th><th align="left">Beta</th><th align="left">VIF</th></tr></thead><tbody valign="top"><tr><td align="left">Emergency remote teaching and learning</td></tr><tr><td align="left">Constant</td><td align="char" char=".">5.097</td><td align="char" char=".">2.467</td><td align="left" /><td align="char" char=".">2.06</td><td align="char" char=".">0.042</td><td align="left" /></tr><tr><td align="left">Frustration<xref ref-type="fn" rid="tfn2" /></td><td align="char" char=".">−0.037</td><td align="char" char=".">0.018</td><td align="char" char=".">−0.203</td><td align="char" char=".">−2.03</td><td align="char" char=".">0.045</td><td align="char" char=".">1.148</td></tr><tr><td align="left">Mini‐lectures<xref ref-type="fn" rid="tfn3" /></td><td align="char" char=".">0.548</td><td align="char" char=".">0.215</td><td align="char" char=".">0.250</td><td align="char" char=".">2.54</td><td align="char" char=".">0.013</td><td align="char" char=".">1.114</td></tr><tr><td align="left">Congruent embodiment while studying<xref ref-type="fn" rid="tfn4" /></td><td align="char" char=".">0.845</td><td align="char" char=".">0.320</td><td align="char" char=".">0.274</td><td align="char" char=".">2.63</td><td align="char" char=".">0.010</td><td align="char" char=".">1.247</td></tr><tr><td align="left">Embodiment during final assessment<xref ref-type="fn" rid="tfn5" /></td><td align="char" char=".">−0.716</td><td align="char" char=".">0.257</td><td align="char" char=".">−0.282</td><td align="char" char=".">−2.78</td><td align="char" char=".">0.007</td><td align="char" char=".">1.186</td></tr><tr><td align="left">Blended learning</td></tr><tr><td align="left">Constant</td><td align="char" char=".">15.609</td><td align="char" char=".">2.373</td><td align="left" /><td align="char" char=".">6.57</td><td align="char" char=".">0.001</td><td align="left" /></tr><tr><td align="left">Temporal demand<xref ref-type="fn" rid="tfn2" /></td><td align="char" char=".">−0.056</td><td align="char" char=".">0.023</td><td align="char" char=".">−0.270</td><td align="char" char=".">−2.38</td><td align="char" char=".">0.021</td><td align="char" char=".">1.045</td></tr><tr><td align="left">Performance<xref ref-type="fn" rid="tfn2" /></td><td align="char" char=".">−0.063</td><td align="char" char=".">0.020</td><td align="char" char=".">−0.362</td><td align="char" char=".">−3.17</td><td align="char" char=".">0.003</td><td align="char" char=".">1.057</td></tr><tr><td align="left">Congruent embodiment during final assessment<xref ref-type="fn" rid="tfn6" /></td><td align="char" char=".">0.746</td><td align="char" char=".">0.270</td><td align="char" char=".">0.309</td><td align="char" char=".">2.76</td><td align="char" char=".">0.008</td><td align="char" char=".">1.013</td></tr></tbody></table> </ephtml> </p> <ulist> <item>2 a NASA‐TLX factors.</item> <item>3 b "I visualized all the 3D videos with attention."</item> <item>4 c Enacting and focusing on body segments while studying.</item> <item>5 d Enacting while taking of final assessment.</item> <item>6 e Enacting and focusing on body segments taking of final assessment.</item> </ulist> <hd id="AN0181847207-21">DISCUSSION</hd> <p>This study aimed first at evaluating the effectiveness of ERTL and BL on anatomy performance in kinesiology students. The second aim was to better understand both ERTL and BL students' performance in interaction with cognitive load, embodied learning, and the use of 3D digital tools.</p> <p>The first notable result revealed that similar performances were found during the ERTL compared with previous F2F conditions, whereas the BL cohort outperformed both ERTL and F2F cohorts. In other words, the rapid transition to online‐only teaching and learning neither enhanced nor deteriorated students' performance. Furthermore, the BL modality appears to be the most efficient. This result differs slightly from previous findings, which have shown either deterioration or enhancement of students' performance following ERTL or BL modalities (e.g., Refs. [[<reflink idref="bib15" id="ref67">15</reflink>], [<reflink idref="bib17" id="ref68">17</reflink>]]). Comparison with previous results is challenging and requires careful consideration for two main reasons: (i) the study programs are not the same; (ii) the teaching modalities and online learning materials made available for students are quite different. For instance, this result appears to be in line with Nathaniel et al.[<reflink idref="bib16" id="ref69">16</reflink>] findings who reported that students' performance was not significantly different from 2019 to 2020. However, when taking a closer look at Nathaniel et al.[<reflink idref="bib16" id="ref70">16</reflink>] results, a higher performance was recorded for the in‐person learning method for one objective, namely, identify and correlate clinical gross anatomical features using common analytic and imaging modalities. This objective is specific to medical studies. Like Nathaniel et al.[<reflink idref="bib16" id="ref71">16</reflink>], most previous investigations (e.g., Refs. [[<reflink idref="bib15" id="ref72">15</reflink>], [<reflink idref="bib18" id="ref73">18</reflink>]]) were conducted in medical studies programs, whereas this study was conducted in kinesiology bachelor program. In medical studies, reproducing the physical and tactile‐based experiences during dissection courses[<reflink idref="bib9" id="ref74">9</reflink>] or clinical case discussions using common analytic and imaging modalities[<reflink idref="bib16" id="ref75">16</reflink>] is not ideal in an online environment. The skills kinesiology students are expected to achieve are not the same (i.e., analyzing the interaction between muscles, joints, and bones during movement; understanding and preventing sports injuries). The only previous research conducted on health sciences students (including kinesiology) is the Diong et al.[<reflink idref="bib17" id="ref76">17</reflink>] study. Interestingly, in Diong et al.[<reflink idref="bib17" id="ref77">17</reflink>] study, the pandemic decreased undergraduate students' (but not postgraduate) performance. In this study undergraduate students' performances did not change compared with F2F. According to Diong et al.[<reflink idref="bib17" id="ref78">17</reflink>], undergraduate students might have needed more structured learning and functional anatomy concepts demonstrations in F2F classes. This assumption is not supported by this present result. The different online content used in both studies may explain these different results. In Diong et al.[<reflink idref="bib17" id="ref79">17</reflink>] study, all lectures were by default recorded during F2F teaching and made available the following year. In line with previous recommendations,[[<reflink idref="bib9" id="ref80">9</reflink>]] this study recorded short 5‐ to 8‐min mini‐lectures using effective 3D animations[<reflink idref="bib21" id="ref81">21</reflink>] and made them available to students. Authors assume that the use of commented short 3D videos as lecture chunks might have explained the absence of performance deterioration during ERTL. This is confirmed by student's satisfaction regarding the efficiency of these short videos and their positive impact on performance, as indicated by the multiple regression linear analysis for the ERTL cohort (see Table 4 and below for more detailed discussion). In sum, for kinesiology students, online‐only modality using adequate digital medium does not deteriorate students' performances compared with F2F courses. Even for the BL modality, using adequate digital tools is crucial. This was confirmed by Yun et al.[<reflink idref="bib18" id="ref82">18</reflink>] study which provided evidence that overall achievement was lower in 2020 than in 2019, except for trunk, head, and neck sessions examination. The practical examination score in the trunk session was significantly higher in 2020 because only professors in charge of the trunk session provided students with 3D digital anatomy educational software.[<reflink idref="bib18" id="ref83">18</reflink>] Furthermore, according to Yun et al.[<reflink idref="bib18" id="ref84">18</reflink>] survey, although the opportunity to participate in the laboratory sessions was reduced (but not canceled!), the 3D tool helped in dissection.</p> <p>The second notable result of this present study is validating the use of online MCQs in kinesiology programs. Indeed, finding similar performances during ERTL compared with F2F validates the rigorous methodology that was followed to transition from paper and pencil to online MCQs. One of the rare studies showing an atypical increase in students' performance during ERTL due to new grading practices is the one conducted by Wilhelm et al.[<reflink idref="bib15" id="ref85">15</reflink>] Authors explained that this increase is due to choosing MCQs instead of short questions during F2F learning phase. The second main explanation they added is that online examinations were not proctored during the pandemic. These two justifications are plausible. As stated by Evans et al.[<reflink idref="bib9" id="ref86">9</reflink>] many educators may have chosen MCQs temporarily during ERTL for ease and reliability. In this current course, MCQs were not chosen neither for ease nor temporarily. MCQs have been used in Lyon 1 University's kinesiology program since the early 2000s. Following Evans et al.[<reflink idref="bib9" id="ref87">9</reflink>] recommendations, anatomy educators of this present study have benefited from the COVID‐19 pandemic to implement a sustained online approach. They followed a rigorous methodology enabling them to implement during ERTL an online non‐proctored MCQs with a slight time constraint (45 min to answer 100 questions instead of 1 h for paper‐based MCQs). The current results provide additional evidence of the validity and reliability of the online MCQs, as demonstrated by comparing the grades of the BL cohort to those of the ERTL cohort. Although the assessment in 2021 (BL cohort) was proctored, grades were significantly higher than in 2020. This result is at odds with Wilhelm et al.[<reflink idref="bib15" id="ref88">15</reflink>] who provided evidence that after implementing software to monitor student activity during online examinations in 2021, examination grades were significantly lower than those observed during ERTL. In sum, online MCQs, when implemented appropriately, are the adequate format of assessment that aligns well with kinesiology programs' teaching and learning activities and learning outcomes.</p> <p>When taking a closer look at the interactions between the post‐course survey items (related to the learning and assessment experience) and ERTL and BL students' performance, the multiple regression linear analyses (Table 4) revealed two interesting results. First, results show a decisive role of congruency between body and mental representations in the enactment process, as it led in both conditions to better performances. For instance, congruent embodiment helped ERTL students while studying during lockdown, whereas, for BL students, it was beneficial during the final proctored assessment. Conversely, the absence of the congruency effect during the final assessment for the ERTL cohort had a detrimental impact on performance, which was positively correlated with the NASA‐TLX frustration factor. In contrast, the authors assume that during the BL final proctored assessment, students controlled their movements and avoided any incongruent movements unrelated to the topic questions. Congruency was already considered an important factor in embodied learning situations using enactment,[[<reflink idref="bib19" id="ref89">19</reflink>], [<reflink idref="bib28" id="ref90">28</reflink>]] but without being explicitly compared with non‐congruent embodiment. This result aligns with Rabattu et al.'s[<reflink idref="bib19" id="ref91">19</reflink>] study on anatomy learning in kinesiology, which found that embodied learning through body movements is most effective when gestures are performed congruently with the content being learned. These are significant findings both pedagogically and scientifically. Previous research shows that movement enactment fosters better embodied digital learning,[[<reflink idref="bib35" id="ref92">35</reflink>]] specifically in the anatomical domain[<reflink idref="bib37" id="ref93">37</reflink>] (Chaker et al. [<reflink idref="bib22" id="ref94">22</reflink>]). The present study identifies domain‐specific congruency effects in digital embodied learning, particularly in anatomy, highlighting the significance of context and situated effects within the broader digital embodied learning paradigm. The second interesting interaction shown by the multiple regression linear analyses is between BL students' performance and both the post‐course survey and the NASA‐TLX items. For instance, workload factors such as temporal demand and performance negatively predict the final score (which is in line with previous results and the structure of the scale; see Refs. [[<reflink idref="bib38" id="ref95">38</reflink>], 38‐40, [<reflink idref="bib39" id="ref96">39</reflink>]], for results in the medical education domain). Furthermore, those two workload items interact negatively with congruent embodiment during the final assessment. These results suggest that focusing on the alignment between body movements and mental representation (i.e., congruent embodiment) during proctored examination reduces the cognitive load and increases performance. This result is unique and novel. This is the first time that the interaction between congruent embodiment and workload factors has been empirically demonstrated based on the results of a study that explicitly discriminated between different levels of embodiment.</p> <p>Finally, the multiple regression linear analyses showed positive effects of 3D video mini‐lectures only for the ERTL cohort. During the summative assessment session, students of the ERTL cohort may have mobilized cognitive resources gained from the 3D mini‐lectures while studying during the semester. This may have compensated for their lack of focus on congruent anatomical movement during assessment. The effectiveness of 3D animations and the significance of mini‐lectures have been extensively documented in the literature (e.g., Refs. [[<reflink idref="bib9" id="ref97">9</reflink>], [<reflink idref="bib21" id="ref98">21</reflink>]]). However, the absence of a positive effect of 3D mini‐lectures in the BL regression model is surprising and challenging to interpret. This may be attributed to the significant changes implemented for the BL cohort, particularly the re‐design of all online activities and the introduction of flipped blended classrooms. That said, this interpretation remains speculative, and further research is required to evaluate the actual impact of both the re‐design of online activities and the introduction of flipped blended classrooms.</p> <hd id="AN0181847207-22">CONCLUSION</hd> <p>The rapid transition to online‐only teaching and learning neither enhanced nor deteriorated students' performance. Furthermore, the BL modality appears to be the most efficient. This efficiency is due to several factors: (i) the use of an adequate format of assessment; (ii) the use of effective 3D mini‐lectures; (iii) the re‐design of online activities; (iv) the introduction of flipped blended classrooms. The use of these online tools as well as the implementation of such pedagogical modalities should align well with the programs' teaching and learning activities and learning outcomes. However, one limitation of this study is that it did not evaluate the specific effects of both the re‐design of online activities and the introduction of flipped blended classrooms. Further research is needed to address these aspects.</p> <p>Congruent embodiment while studying functional anatomy leads to better performance. On the other hand, when embodiment is not congruent, especially during assessment, performance is negatively impacted. Non‐congruent embodiment in anatomical education impairs performance by inducing additional cognitive load. Further research is needed to identify the quality and quantity of congruency and evaluate its impact on learning outcomes.</p> <p>This study was conducted in a real classroom context which includes all its inherent limitations. These include variability in classroom dynamics and individual student differences that are difficult to control for. Additionally, the study involved different cohorts that were not randomly assigned, which may introduce biases and affect the generalizability of the findings.</p> <hd id="AN0181847207-23">AUTHOR CONTRIBUTIONS</hd> <p>Rawad Chaker contributed to the study design, conducted the data analysis, participated in drafting the manuscript, and proofread the final version. Mélanie Gallot collected the data and contributed to drafting the manuscript. Ayodélé Madi participated in drafting the manuscript. Christian Collet was involved in designing the study and proofread the final version. Nady Hoyek played a role in designing the study, wrote the main draft, and proofread the final version.</p> <hd id="AN0181847207-24">ACKNOWLEDGMENTS</hd> <p>This work was partly supported by the SHIFT French national project. Grant number: ANR‐20‐FTAP‐0002. We thank Alaa Bitar for helping us in setting the online NASA‐TLX test.</p> <ref id="AN0181847207-25"> <title> REFERENCES </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Bozkurt A, Jung I, Xiao J, Vladimirschi V, Schuwer R, Egorov G, et al. A global outlook to the interruption of education due to COVID‐19 pandemic: navigating in a time of uncertainty and crisis. Asian J Dist Educ. 2020 ; 15 (1): 1 – 126.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref2" type="bt">2</bibl> <bibtext> Ashraf MA, Yang M, Zhang Y, Denden M, Tlili A, Liu J, et al. A systematic review of systematic reviews on blended learning: trends, gaps and future directions. Psychol Res Behav Manag. 2021 ; 14 : 1525 – 1541.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref5" type="bt">3</bibl> <bibtext> Müller C, Mildenberger T. Facilitating flexible learning by replacing classroom time with an online learning environment: a systematic review of blended learning in higher education. 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Student learning of head and neck anatomy using cone beam computed tomography and immersive virtual reality. J Dent Educ. 2023 ; 87 (8): 1180 – 1187.</bibtext> </blist> <blist> <bibtext> Said S, Gozdzik M, Roche TR, Braun J, Rössler J, Kaserer A, et al. Validation of the raw national aeronautics and space administration task load index (NASA‐TLX) questionnaire to assess perceived workload in patient monitoring tasks: pooled analysis study using mixed models. J Med Internet Res. 2020 ; 22 (9): e19472.</bibtext> </blist> </ref> <aug> <p>By Rawad Chaker; Mélanie Gallot; Ayodélé Madi; Christian Collet and Nady Hoyek</p> <p>Reported by Author; Author; Author; Author; Author</p> <p></p> <p>Rawad Chaker, Ph.D. is an associate professor of educational sciences, in the Institute of Educational and Training Sciences and Practices at Lyon 2 University. He specializes in digital technology for education and training, focusing on various issues related to design, integration, and use. His research projects cover digital environments (virtual reality, simulation, learning spaces), school robotics, e‐instructional design, hybrid/distance learning (MOOCs, e‐learning, etc.), learning analytics, and skills development.</p> <p>Mélanie Gallot, Ph.D. is a postdoctoral fellow in the Inter‐University Laboratory of Human Movement Science, Villeurbanne, France. She teaches human anatomy to first‐year kinesiology students and her research interest is in the impact of digital tools interaction on learning human anatomy.</p> <p>Ayodélé Madi is a head teacher for clinical training in the Physiotherapy Department of the ISTR‐Lyon1, France. She teaches human anatomy and clinical reasoning to physiotherapy students and kinesiology students, and her research interest is the impact of embodiment on the acquisition of technical skills.</p> <p>Christian Collet, Ph.D. is a full professor of cognitive neuroscience, in the Department of kinesiology in Lyon 1 University in Villeurbanne, France. He is also a researcher at the Inter‐University Laboratory of Human Movement Science, Villeurbanne, France. He teaches cognitive neuroscience and human motor control to third‐year and Master degree kinesiology students. His research interest is in the neural correlates of mental and motor imagery. Spatial ability in learning.</p> <p>Nady Hoyek, Ph.D. is an associate professor of cognitive neuroscience, in the Department of kinesiology in Lyon 1 University in Villeurbanne, France. He is also a researcher at the Inter‐University Laboratory of Human Movement Science, Villeurbanne, France. He teaches human anatomy to first‐year kinesiology students and his research interest is in the impact of digital tools interaction on learning human anatomy.</p> </aug> <nolink nlid="nl1" bibid="bib10" firstref="ref12"></nolink> <nolink nlid="nl2" bibid="bib11" firstref="ref13"></nolink> <nolink nlid="nl3" bibid="bib12" firstref="ref14"></nolink> <nolink nlid="nl4" bibid="bib13" firstref="ref16"></nolink> <nolink nlid="nl5" bibid="bib15" firstref="ref17"></nolink> <nolink nlid="nl6" bibid="bib16" firstref="ref18"></nolink> <nolink nlid="nl7" bibid="bib17" firstref="ref19"></nolink> <nolink nlid="nl8" bibid="bib18" firstref="ref20"></nolink> <nolink nlid="nl9" bibid="bib19" firstref="ref30"></nolink> <nolink nlid="nl10" bibid="bib20" firstref="ref31"></nolink> <nolink nlid="nl11" bibid="bib21" firstref="ref32"></nolink> <nolink nlid="nl12" bibid="bib22" firstref="ref34"></nolink> <nolink nlid="nl13" bibid="bib23" firstref="ref35"></nolink> <nolink nlid="nl14" bibid="bib24" firstref="ref36"></nolink> <nolink nlid="nl15" bibid="bib25" firstref="ref37"></nolink> <nolink nlid="nl16" bibid="bib26" firstref="ref38"></nolink> <nolink nlid="nl17" bibid="bib28" firstref="ref39"></nolink> <nolink nlid="nl18" bibid="bib29" firstref="ref41"></nolink> <nolink nlid="nl19" bibid="bib30" firstref="ref44"></nolink> <nolink nlid="nl20" bibid="bib31" firstref="ref48"></nolink> <nolink nlid="nl21" bibid="bib32" firstref="ref55"></nolink> <nolink nlid="nl22" bibid="bib33" firstref="ref62"></nolink> <nolink nlid="nl23" bibid="bib34" firstref="ref64"></nolink> <nolink nlid="nl24" bibid="bib35" firstref="ref92"></nolink> <nolink nlid="nl25" bibid="bib37" firstref="ref93"></nolink> <nolink nlid="nl26" bibid="bib38" firstref="ref95"></nolink> <nolink nlid="nl27" bibid="bib39" firstref="ref96"></nolink>
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  Data: Teaching Human Anatomy before during and after COVID-19 Pandemic: A Longitudinal Study on Kinesiology Students' Performance, Cognitive Load, and Congruent Embodied Learning
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  Data: <searchLink fieldCode="AR" term="%22Rawad+Chaker%22">Rawad Chaker</searchLink><br /><searchLink fieldCode="AR" term="%22Mélanie+Gallot%22">Mélanie Gallot</searchLink><br /><searchLink fieldCode="AR" term="%22Ayodélé+Madi%22">Ayodélé Madi</searchLink><br /><searchLink fieldCode="AR" term="%22Christian+Collet%22">Christian Collet</searchLink><br /><searchLink fieldCode="AR" term="%22Nady+Hoyek%22">Nady Hoyek</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-1093-0263">0000-0003-1093-0263</externalLink>)
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  Data: <searchLink fieldCode="SO" term="%22Anatomical+Sciences+Education%22"><i>Anatomical Sciences Education</i></searchLink>. 2025 18(1):48-58.
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  Data: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
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  Data: 11
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  Data: Journal Articles<br />Reports - Research
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  Data: <searchLink fieldCode="DE" term="%22Anatomy%22">Anatomy</searchLink><br /><searchLink fieldCode="DE" term="%22Human+Body%22">Human Body</searchLink><br /><searchLink fieldCode="DE" term="%22Kinesiology%22">Kinesiology</searchLink><br /><searchLink fieldCode="DE" term="%22Science+Instruction%22">Science Instruction</searchLink><br /><searchLink fieldCode="DE" term="%22COVID-19%22">COVID-19</searchLink><br /><searchLink fieldCode="DE" term="%22Pandemics%22">Pandemics</searchLink><br /><searchLink fieldCode="DE" term="%22Electronic+Learning%22">Electronic Learning</searchLink><br /><searchLink fieldCode="DE" term="%22Blended+Learning%22">Blended Learning</searchLink><br /><searchLink fieldCode="DE" term="%22In+Person+Learning%22">In Person Learning</searchLink><br /><searchLink fieldCode="DE" term="%22Science+Achievement%22">Science Achievement</searchLink><br /><searchLink fieldCode="DE" term="%22Teaching+Methods%22">Teaching Methods</searchLink><br /><searchLink fieldCode="DE" term="%22Instructional+Effectiveness%22">Instructional Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Difficulty+Level%22">Difficulty Level</searchLink><br /><searchLink fieldCode="DE" term="%22Cognitive+Processes%22">Cognitive Processes</searchLink><br /><searchLink fieldCode="DE" term="%22Technology+Integration%22">Technology Integration</searchLink><br /><searchLink fieldCode="DE" term="%22Computer+Assisted+Instruction%22">Computer Assisted Instruction</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1002/ase.2532
– Name: ISSN
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  Group: ISSN
  Data: 1935-9772<br />1935-9780
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: During the COVID-19 pandemic, anatomy educators have demonstrated their ability to respond to face-to-face (F2F) teaching restrictions and offer emergency remote teaching and learning (ERTL) approach. Another educational model that was intensified during COVID-19 was blended learning (BL) which is a combination of F2F and online settings. Studies on the effects of the methods employed during COVID-19 pandemic on anatomy students' learning outcomes are sparse and show slightly similar but nuanced results. There is poor evidence on how the transition to online-only or to BL in response to COVID-19 impacted anatomy students' performance, cognitive load, and embodied learning. The main aim of this longitudinal study is to evaluate the effectiveness of ERTL and BL on anatomy performance in kinesiology students. The second aim of this study was to better understand students' performance in terms of cognitive load embodied learning, and the use of 3D digital tools. The results indicate no significant differences between F2F and ERTL students' performance. However, the results yielded significantly better performance for the BL students in comparison with both F2F (p = 0.001) and ERTL cohort (p = 0.001). The rapid transition to online-only teaching and learning neither enhanced nor deteriorated students' performance. The BL modality appears to be the most efficient. Learning outcomes were discussed in relation to cognitive load, embodied learning, and the use of 3D digital tools.
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  Data: 2024
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  Data: EJ1454931
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        Value: 10.1002/ase.2532
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      – Text: English
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        StartPage: 48
    Subjects:
      – SubjectFull: Anatomy
        Type: general
      – SubjectFull: Human Body
        Type: general
      – SubjectFull: Kinesiology
        Type: general
      – SubjectFull: Science Instruction
        Type: general
      – SubjectFull: COVID-19
        Type: general
      – SubjectFull: Pandemics
        Type: general
      – SubjectFull: Electronic Learning
        Type: general
      – SubjectFull: Blended Learning
        Type: general
      – SubjectFull: In Person Learning
        Type: general
      – SubjectFull: Science Achievement
        Type: general
      – SubjectFull: Teaching Methods
        Type: general
      – SubjectFull: Instructional Effectiveness
        Type: general
      – SubjectFull: Difficulty Level
        Type: general
      – SubjectFull: Cognitive Processes
        Type: general
      – SubjectFull: Technology Integration
        Type: general
      – SubjectFull: Computer Assisted Instruction
        Type: general
    Titles:
      – TitleFull: Teaching Human Anatomy before during and after COVID-19 Pandemic: A Longitudinal Study on Kinesiology Students' Performance, Cognitive Load, and Congruent Embodied Learning
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Rawad Chaker
      – PersonEntity:
          Name:
            NameFull: Mélanie Gallot
      – PersonEntity:
          Name:
            NameFull: Ayodélé Madi
      – PersonEntity:
          Name:
            NameFull: Christian Collet
      – PersonEntity:
          Name:
            NameFull: Nady Hoyek
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 1935-9772
            – Type: issn-electronic
              Value: 1935-9780
          Numbering:
            – Type: volume
              Value: 18
            – Type: issue
              Value: 1
          Titles:
            – TitleFull: Anatomical Sciences Education
              Type: main
ResultId 1