Learning the nature of the musculoskeletal system—including bones, muscles, innervations, and movements—can be a daunting challenge. While a few nascent orthopedists may be excited to learn the myriad of muscular origins and attachments, some students find traditional learning approaches, such as lecture and cadaveric dissection, difficult, if not overwhelming (McLachlan et al., 2004). In recent years, a number of novel approaches, ranging from interactive computer-assisted modules to clay modeling and body painting, have augmented standard curricula and engaged both faculty and students in new ways (Reidenberg and Laitman, 2002; Bryner et al., 2008; McMenamin, 2008; McNulty et al., 2009; Motoike et al., 2009; Petersson et al., 2009).
While the above approaches have exploited manual and visuospatial relationships, one segue which has not been as robustly tapped is the integration of physical exercise with anatomy. Incorporating such an integration into an anatomy curriculum seems both timely and important, as our society has become increasingly more conscious of the value of physical health, an active lifestyle, and “wellness” (Zimmer, 2010).
This article presents four years' research on Living AnatoME (LA) (formerly called the Living Anatomy Project), a student-initiated approach developed at the Mount Sinai School of Medicine in New York, NY that augmented standard teaching by allowing students and faculty to learn about their body movements and the underlying anatomy through yoga and Pilates. It was felt that melding such exercises with anatomical information would allow for the transmission of facts within a novel and enjoyable experience, resulting in enhancement of medical students': (1) anatomy comprehension, (2) physical awareness, and (3) relaxation/well-being.
Background of Living AnatoME: Incorporating Yoga and Pilates into the Medical Curriculum
Yoga and Pilates are popular mind-body disciplines; inherent to both is a functional application of anatomy that aims to enhance physical awareness. Yoga (“union” in Sanskrit) is a physical and mental discipline dating back millennia that often encompasses the pursuit of an individual's union with a “true, inner self” via ritualized movements, breathing, and meditation (Satchidananda, 1990; Feuerstein, 2001). Hatha yoga, a popular type practiced in the West, is comprised of a series of asanas, or poses, like the well-known “downward dog” pose. Asanas are typically performed in sequence, originally under the apprenticeship of a guru, and now in gyms and studios nationwide. Hatha yoga began in the 10th century CE, coinciding with the “Golden Age of Indian Medicine,” a time when Indian anatomists began their own investigations through human dissection (800 BCE – 1000 CE) (Rajgopal et al., 2002).
Unlike the ancient practice of yoga, Pilates originated in the early 20th century with the work of German-born Joseph Pilates. After years of studying several mind-body disciplines including yoga, Zen, and ancient Greek and Roman exercise regimes, Pilates developed his own method called “Contrology.” This physical movement program consists of hundreds of exercises and is designed to stretch, strengthen, and bring balance to the body. Core principles of the method include awareness of breath, strengthening of core musculature, and promotion of proper posture. Years after Pilates' death, Contrology has become a popular fitness modality throughout the world, and is now known as Pilates (for discussion of Pilates, see PMA, 2006).
In 2004, as first-year medical students in the Gross Anatomy course at Mount Sinai, C.M. (a Pilates instructor) and S.P.M. (a yoga instructor), in conjunction with the Anatomy Course Director (J.T.L.), created the LA program as a method of helping their fellow classmates review musculoskeletal anatomy through yoga and Pilates. The LA program consisted of a series of classes that used specific yoga and Pilates exercises to demonstrate and review musculoskeletal anatomy material taught in the Gross Anatomy curriculum. The program was implemented at Mount Sinai School of Medicine from 2004 to 2006 as elective classes in which medical students could voluntarily partake. Survey feedback collected during this time demonstrated the LA program's positive impact on students': (1) self-perceived enhancement of musculoskeletal anatomy comprehension, (2) physical awareness, and (3) relaxation/well-being; this survey data also revealed that students believed “physical awareness” and “well-being” were important elements of both their medical education and clinical careers (Sager et al., 2005, 2006; Pieczenik et al., 2006, 2007, 2008). Based on this positive feedback, the LA program was expanded and officially integrated into the Gross Anatomy curriculum in the Fall Semester of 2007.
This article reports the analysis of the LA program subsequent to its incorporation into the Gross Anatomy curriculum. The central research question addressed was whether or not the LA program objectively improved medical student comprehension of musculoskeletal anatomy material. Additionally, building on previously collected data, this study further assessed the LA program's impact on students' perceived physical awareness and relaxation/well-being.
Setting and Participants
The subjects of this research were first-year medical students (n = 144) enrolled in the 2007 Gross Anatomy course (∼140 contact hours, lectures and laboratories, from September to the end of December) at the Mount Sinai School of Medicine in New York, NY. All students participating in this research previously completed the traditional musculoskeletal gross anatomy curriculum on the upper and lower limbs (seven hours of lectures and small-group discussions, and six laboratories totaling 22 hours); these lectures and laboratories concluded several days before students participated in an LA session. Students signed up to take a one and half-hour LA session on the upper and lower limbs; six identical sessions were held accommodating ∼28 students per session.
These LA sessions consisted of a series of yoga and Pilates exercises that demonstrated specific musculoskeletal anatomy of the upper and lower limbs.
The format was created to promote active learning; during the class, leaders demonstrated regional musculoskeletal anatomy and clinical correlates while participating students performed exercises that recruited the featured musculature. The class format was delineated as follows:
Students started with a five-minute warm-up to physically prepare for class.
Then, yoga and Pilates exercises that demonstrated specific musculoskeletal anatomy were first shown by the leaders (Fig. 1), and then performed by participants while the leaders verbally reinforced anatomy and assisted students through the exercises (Fig. 2). Resistance bands were sometimes used to help students feel the muscular emphasis of an exercise. In addition to correlating anatomy with movement, the classes also integrated information on clinical correlates and palpation practice.
Leaders concluded with an interactive question-and-answer session to reinforce material. Students finished with a closing “Savasana” (Fig. 3), for integration and relaxation.
All sessions were held in the student lounge; a local Pilates studio donated equipment used for the sessions, including exercise mats and resistance bands.
All anatomical information emphasized during the LA session had been previously covered in lectures and laboratories, and was limited to the following categories: muscle function, innervation, muscle attachment and location, muscle and bony landmark palpation, and clinical correlates.
Eighty-four of the 144 gross anatomy students who participated in an LA session completed both a pre- and a post-test. Our analysis focused on these 84 students.
The pre- and post-tests were identical, self-administered, closed-book, online examinations given 1–3 days before and 10–12 days following the LA session, respectively. Each test was comprised of 25 multiple-choice questions: 20 regarding items taught in the LA session and five nonrelated items included as a control. The 20 LA-related questions tested knowledge in the following seven domains: lower limb, upper limb, muscle function, innervation, attachment/location, palpation, and clinical correlate. Some of the aforementioned questions tested material in more than one area (i.e., lower limb and muscle function). The five control questions assessed knowledge of anatomy material that was not covered during the LA session (i.e., blood supply). Questions were designed to be straightforward, ranging from assessments of baseline factual musculoskeletal knowledge (i.e., the function of the gluteus medius) to expected applications of clinical knowledge for a first-year student (i.e., the name of the nerve damaged in a mastectomy procedure, resulting in “winged scapula”). Analysis of the pre- and post-test results was conducted using SAS statistical software, version 9.2 (SAS Institute, Cary, NC).
In addition to the pre- and post-test, all 144 students completed an anonymous, online subjective evaluation of the LA program following the end of the Gross Anatomy course. This evaluation was part of the required post-course evaluations conducted on all curricular activities at Mount Sinai. The survey consisted of 20 questions (one open-ended and nineteen Likert-scale type questions) evaluating the students' perceptions of the LA's impact on their: anatomy comprehension (e.g., “the integration of anatomy and movement improved my ability to understand the function of the limbs”), physical awareness (e.g., “the use of movement helped me understand the location and function of my own muscles”), and relaxation/well-being (e.g., “the LA was an effective way to relax while learning”). The complete survey is available from authors upon request.
Analysis of the data was separated into two categories: objective (based on pre- and post-tests) and subjective (based on student surveys).
The data, outlined in Table 1, revealed significant improvement in Total LA scores, as well as in the domains of upper limb, muscle function, and palpation following an LA session (P < 0.05). Post-test performance also increased in the domains of lower limb, attachment/location, and clinical correlate, but not to a significant degree. Performance in the domain of innervation remained the same before and after the LA session. Additionally, performance on control group questions (e.g., non-LA related material) also improved, but not significantly.
Table 1. Living AnatoME Pre- and Post-Test Results
The majority of students responded positively (e.g., “agree” or “strongly agree”) to 17 of 19 questions assessing the LA's impact on their anatomy comprehension, physical awareness, and relaxation/well-being:
In the realm of anatomy comprehension, 70% of students surveyed agreed that the LA increased their understanding of anatomic structures (e.g., the location of the sartorius muscle), 67% agreed that the LA class improved their understanding of joint movements (e.g., abduction of the arm); additionally, 76 and 78% of students agreed that dissemination of anatomical information in a nontraditional learning environment and via a hands-on process, respectively, reinforced their learning.
Regarding physical awareness, 44% of students agreed that their personal sense of physical awareness increased as a result of attending an LA class, 53% agreed that the class improved their ability to locate/palpate anatomical structures on their own body, and 76% agreed that movement helped them learn about the location and function of their own muscles; additionally, 77% agreed that physical awareness was an important characteristic for a physician to have. Survey data also showed that 69% of students agreed that they derived a greater sense of relaxation and well-being as a result of attending an LA class, and 85% agreed that relaxation and well-being improved their performance as medical students.
Student open-ended comments were also recorded; the majority of these comments reflected a positive student experience. Themes of student comments included enjoyment of the LA's practical application of anatomy, enhancement of physical awareness, nontraditional learning environment, and relaxing and fun qualities. Criticism of the project mainly fell under three categories: (1) dislike of mandatory element of class, (2) dislike of singular class/request to include multiple classes throughout the semester to enhance learning, and (3) dislike of interrupted flow of yoga and Pilates when anatomy discussion became lengthy. Excerpts of comments are listed in Table 2.
Table 2. Student Comments on the Living AnatoME Session
Student Benefits from LA
Adding to the data collected from previous years, data from this study supports the hypothesis that melding yoga and Pilates exercises with anatomical information would allow for the transmission of facts within a novel and enjoyable experience, resulting in an enhancement of medical students': (1) anatomy comprehension, (2) physical awareness, and (3) relaxation/well-being.
Increased Anatomy Comprehension
Data from this study demonstrated two separate but related points regarding anatomy comprehension. First, overall, this study revealed a statistically significant increase in student comprehension of musculoskeletal anatomy following participation in an LA session, as evaluated through pre- and post-testing. Second, survey feedback from this study further supported previous findings, demonstrating students' perception of increased comprehension of musculoskeletal anatomy following participation in an LA session. Survey feedback also pointed to potential factors underlying this improvement: the majority of students surveyed agreed that dissemination of anatomical information in a nontraditional learning environment and via a hands on-process positively impacted their learning.
Increased Physical Awareness
Survey data showed that LA imparted a greater understanding of students' physical selves. An equally important corollary was that the majority of students believed that physical awareness was an important characteristic for a physician to have. This latter perception points to the potentially vital—but currently underserved—role that learning about one's self may play in the education of a health professional. This student belief not only supports the educational goals of the LA program, but also warrants further study and possible inclusion of more physical-awareness based programs in medical curricula.
Increased Relaxation and Well-Being
Survey data showed the majority of students derived a greater sense of relaxation and well-being as a result of attending an LA class. Of equal importance, the majority of students also agreed that relaxation and well-being improved their performance as medical students. It is known through both life experience and research that stress reduction and relaxation can positively impact the quality and longevity of one's life (Saihara et al., 2010); operating under perpetually high levels of stress, medical students can only benefit from the incorporation of relaxation into their days.
Another component of well-being derived from the LA class was exercise. Under the pressure of constant evaluations and examinations, students may not have time to exercise their bodies nearly as much as their brains (Vitaliano et al., 1984; Dyrbye et al., 2005). The LA classes permitted students to undertake physical activity without the associated guilt of not studying; said one student from a 2005 class, “I enjoy yoga and Pilates but I find it hard to make time for classes. [LA] allowed me to do exercises while not feeling guilty that I was losing studying time.”
Study Design Issues
Ideally, this study would have benefited from a randomized, controlled design in which one group of students participated in an LA session and another group participated in an additional curricular activity, such as extra laboratory or supervised study time. Due to the difficult nature of mandating different curricular activities for students, this type of study design could not be used.
In lieu of a randomized control design, this study incorporated “control” questions into the pre- and post-test. As described earlier, these questions assessed knowledge of anatomy material covered in the traditional curriculum but not in the LA session (e.g., blood supply). Including these questions on the evaluation afforded a method of analyzing possible reasons for changes in student performance on the pre- and post-tests. For example, increased performance on the post-test (which was administered 10–12 days following the LA session) could have been attributed to either student participation in the LA session or simply a result of additional study time. Control group questions were used to analyze the role of non-LA related factors on test performance.
Objectively, there was increased performance on the post-test (in total LA scores as well as in the domains of upper limb, muscle function, and palpation). These results support the LA's efficacy in teaching anatomy. However, student performance on the control group questions also increased, although not to a statistically significant degree. Additionally, students performed better at a statistically significant level in certain domains (e.g., upper limb), but not in other related areas (e.g., lower limb). The factors underlying these results are unclear, but they may point to the role of other variables (e.g., additional study time, curricula/lecturer focus) that may account for the increase in student post-test performance.
Another potential issue with the research design was the relatively small number of questions allotted to categories on the pre- and post-tests. A limited number of questions were chosen to avoid overwhelming first-year medical students with lengthy evaluations, which, as our experience has shown, can reduce student compliance. Nevertheless, this element of the study design hindered a complete assessment of the LA's efficacy in enhancing student performance in certain categories (e.g., palpation, which included only two questions). Additionally, student compliance issues were encountered in completing the pre-and post-tests; only 84 out of the total 144 students who participated in the LA session completed both the pre- and post-tests. This incomplete compliance may have introduced an element of selection bias into the study.
Further studies are needed to more accurately analyze the effect of the LA program on student comprehension; considerations for future study designs include: (1) use of a randomized control group study design, (2) implementation of a more in-depth LA curriculum (with five to six sessions, instead of one), and (3) the addition of a longitudinal evaluation that assessed students' knowledge at one to two years post-curricular intervention.
Implications for Anatomy Curricula/Educators
LA may be a valuable adjunct to the teaching and learning of musculoskeletal anatomy, as shown by the results of this study. In conjunction with traditional lecture and laboratory format, LA classes may impart an increased functional understanding of the human body. The LA class format, integrating lecture, demonstrations, and movement, is aligned with the principles of the visual, aural/auditory, read/write, kinesthetic (VARK) educational theory (Fleming, 2010), which may help explain the efficacy of the LA classes. According to this theory, students have preferences for the way in which they receive information. The VARK school explains that there are four types of learning: visual, aural/auditory, reading/writing, and kinesthetic (Fleming and Mills, 1992; Fleming, 2010). Visual learners understand through seeing image-rich material such as pictures, diagrams, and demonstrations. Auditory learners best comprehend through lecture and discussion. Readers/writers understand material through interaction with textual materials. Kinesthetic learners rely upon experience, physical involvement, and manipulation of objects. Students can be uni-modal learners, preferring information presented according to only one of the four VARK types, or they can be multimodal learners, drawing upon two to four of the types (Fleming and Mills, 1992; Fleming, 2010). Three previous independent VARK studies performed on first year medical students confirmed that the majority of students are multimodal learners, and that largest group of the remaining uni-modal learners was represented by kinesthetic learners (Lujan and DiCarlo, 2006; Bykan and Naçar, 2007; Lufler et al., 2010).
As the LA classes are multimodal, incorporating auditory, visual, and kinesthetic elements, they represent a possible new direction that anatomy education can take, as part of a diverse, active lesson plan conducive to all realms of learning. This model is timely, given the recent reports of declining anatomical knowledge within the medical field, and the simultaneous undertaking of the discipline to reinvent itself, moving toward a more functionally and clinically relevant anatomy curricula (Turney, 2007). Nonetheless, functional anatomy, like stance and gait, “are of considerable clinical relevance, but are rarely taught explicitly” (Miller, 2000). Only a minority of programs, such as the “muscle-cut out exercise” at the University of Cape Town in South Africa, are hands-on in their approach to imparting this level of understanding (Gangata, 2008).
Additionally, the structure and focus of an LA class can be easily modified, a feature that educators may find useful in serving the distinct needs of their individual curricula. For example, during its evolution at Mount Sinai, the LA program was once offered as a multipart elective series designed to accompany all musculoskeletal portions of the Gross Anatomy curriculum (back, thorax and abdomen, upper limb, and lower limb). The LA program was also integrated into the second-year clinical skills course (Art and Science of Medicine II) and third-year elective module (Intersession) at Mount Sinai School of Medicine; LA sessions tailored for these classes contained higher levels of clinical information to facilitate second- and third-year students' application of musculoskeletal knowledge (Pieczenik et al., 2007).
The inclusion of physical exercise and body awareness as teaching tools in anatomy curricula, as exemplified by our use of yoga and Pilates, appears to be a valuable adjunct to anatomical education. In addition to facilitating retention of musculoskeletal information and promoting physical health, infusion of activities such as the LA, which also promote enjoyment and mental health, add to the robustness of our educational world. Furthermore, given the changing face of our student population, ever more cognizant of well-being and the need for it, it is imperative to incorporate more educational endeavors that link learning to one's own health. After all, physicians should practice what they preach, and anatomists can lead the way in showing them how.
NOTES ON CONTRIBUTORS
CARRIE McCULLLOCH, M.D., is the medical director of Kinected, an integrative Pilates center in New York, New York. She graduated from the Mount Sinai School of Medicine in New York in 2009 with Distinction in Research and received the 2006 NorthEast Group on Educational Affairs (of the AAMC) Award for Innovation in Pre-Clinical Medical Student Education for her work integrating yoga and Pilates into the teaching of musculoskeletal anatomy.
STEPHANIE PIECZENIK MARANGO, M.D., is a yoga therapist and a recent graduate of California Pacific Medical Center's psychiatry internship in San Francisco, California. She graduated from the Mount Sinai School of Medicine in New York in 2009 with Distinction in Research and received the 2006 NorthEast Group on Educational Affairs (of the AAMC) Award for Innovation in Pre-Clinical Medical Student Education for her work integrating yoga and Pilates into the teaching of musculoskeletal anatomy.
ERICA S. FRIEDMAN, M.D., is an associate professor of medical education and medicine at Mount Sinai School of Medicine, New York, New York. She is also an Associate Dean for Education Assessment and Scholarship and Director of the Morchand Center for Clinical Competence. She has particular interests, and is nationally recognized as a leader, in curricular design and assessment.
JEFFREY T. LAITMAN, Ph.D., is Distinguished Professor of the Mount Sinai School of Medicine, New York, New York; Professor and Director of the Center for Anatomy and Functional Morphology, Professor of Otolaryngology and Professor of Medical Education at Mount Sinai; and Professor of Anthropology of the Graduate School of the City University of New York, NY. He is also the Director of the Gross Anatomy Course and the President-Elect of the American Association of Anatomists.