TABLE OF CONTENTS
LIST OF FIGURES
LIST OF TABLES.
LIST OF APPENDICES
LIST OF DEFINITIONS
CHAPTER 1: Introduction
Goal & Objectives
CHAPTER 2: Review of Existing Literature.9
Introduction and Interactive Programs in Medical Education…...9
Enduring Understanding Principals The Basics of the Cerebellum…
Cerebellar Cortex Anatomy
Functional Divisions and Pathway Projections
Current Resources and Related Materials
CHAPTER 3: Conceptual Framework and Methodology
Visuals and Teaching Method
Target Audience Goals and Objectives
Final Content Proposal
Storyboards and Scripts
Layout Design and Style Sheets
Visual Organization and Typography
Menus and Submenus
Software Used in Production
Review and Revisions
CHAPTER 4: Results…58
Pre and Post Testing
CHAPTER 5: Conclusions and Recommendations
Recommended Areas of Further Study
No prior publications
LIST OF FIGURES
FIGURE 2.1 SALOMON’S NEUROANATOMY
FIGURE 2.2 THE CENTRE FOR NEUROSKILLS
FIGURE 2.3 THE CENTRAL NERVOUS SYSTEM
FIGURE 3.1 GROSS ANATOMY STYLE SHEET
FIGURE 3.2 3D MODEL STYLE SHEET
FIGURE 3.3 COLORS PALETTE
FIGURE 3.4 MENUS STYLE
FIGURE 3.5 3D MODEL
FIGURE 3.6 3D MODEL IN FLASH
FIGURE 3.7 2D DRAWINGS OF IMAGE
FIGURE 3.8 FINAL 3D MODEL OF CELLS IN FLASH
FIGURE 3.9 PROJECTION PATHWAYS IN FLASH
LIST OF TABLES
TABLE 4.1 EVALUATION RESULTS
TABLE 4.2 PRE TEST AND POST TEST SCORE PERCENTAGES
TABLE 4.3 PRE TEST AND POST TEST RESULTS
LIST OF APPENDICES
LIST OF DEFINITIONS
CHAPTER ONE Introduction
Can an interactive program be designed to specifically aid medical students’ retention and recall of cerebellar circuitry at specific points in their medical education?
GOALS & OBJECTIVES
The project goal was to produce an interactive web-based flash program to aid in medical students’ retention of cerebellar circuitry at specific instances in their medical education. The program would be usable in sequential steps during a student’s medical education: during the first year neuroscience course, as a helpful guide during their boards, and finally as an aid during residency. The main objective is to provide students with clear, easily understandable, base visuals functional in a variety of levels of informational content. Likewise, it should describe cerebellar circuitry and pathways with comprehensive user-controlled interactive diagrams. Also, it should contain a more logical diagram and 3D model of cerebellar circuitry for study and clarity of dimensionality than are currently available.
The program is intended for medical students at varying levels during their medical education. The target audience can be broken into three specific groups. The first target group is medical students taking medical neuroscience for the first time during their first or second year of medical school. Such a group of students would have either a basic or limited understanding of neuroanatomy and physiology. The second target group is students reviewing the information for their boards during the summer after their second year of medical school. This group would need a program designed for study but also to serve as a refresher to major information vital to their upcoming exams. The third target group is medical residents beginning in neuroscience and neuropathology residencies and requires a program which concisely expresses the information necessary to make clinical correlations to specific pathology and disease.
The rigors of medical school can prove a challenge to even the most equipped students. In today’s top medical programs, students are expected not only to know more information than in the past, but know it quicker, and in greater detail. Students are required to make large scale clinical inferences about course material to succeed. Presented with such obstacles many students are overwhelmed. In one medical school study, it was found that“…students have too few cognitive resources to optimally retrieve information from long term memory, which may seriously hamper learning” (van Hell et al 835).
Given these challenges, some schools are trying a new approach to learning referred to as enduring learning. Guised under multiple names from “enduring learning” to “unit based correlative visual frameworks,” the concept remains the same — identification of key concepts and consistent visualization is crucial. One such school adding the concept of enduring learning to its curriculum is the Mayo Clinic. In the Mayo Clinic M. D. curriculum objectives, enduring learning and an understanding of core competencies are listed as one of their primary purposes (Mayo 1).
Presently multiple programs are in circulation which provide students with basic neuroanatomical information, but many of these programs fail to provide information for continued learning, or lack core concepts. None yet exist which implement the concept of enduring learning style into the structure of their program.
Prior to the development of the program, the core objectives had to be identified. The core concept of the cerebellum was determined based on the current medical neuroscience course syllabus objectives. These objectives were adequately structured to handle the needs of the enduring-learning style. Upon completion of the program the medical student will be able to:
1. Name the major internal and external cerebellar cortical structures
including: hemispheres, tonsils, flocculus, nodulus, and vermis, as well as midsaggital and parasaggital structures.
2. Properly identify the cerebellar peduncles and their specific afferent and efferent projections.
3. Identify the three layers of the cerebellar cortex, name which cells lie in each area, and describe how these cell types interact.
4. Identify specific cerebellar cortex cells.
5. Describe which cell types carry information to and from the cerebellum.
6. Identify the three major functional divisions of the cerebellum and be able to describe their afferent and efferent pathways.
7. Determine functional deficiencies determined by abnormalities to the structures previously described.
This project is concerned with the amount of information forgotten and lost by medical students during their years of education. We hope to provide a supplement to the current syllabus that would aid in increasing students retention of information on the cerebellum and decrease cognitive load.
There are many resources available to students to assist in learning about the cerebellum, from three-dimensional models of the brain to cortical dissection slides. None of the programs combined the information from multiple levels of education to create one cohesive understanding of the cerebellum. This program offers a consolidated visual focus incorporating many different available resources as well as concise information to aid in recall and recovery during study.
The current images and interactive programs available to the student, either through the library or online provide information on basic neuroanatomy and slides with minimal activity and no further application. Some of these programs provided quiz sections. Unfortunately though, these quiz questions tested only basic anatomical structures. We hope to crease a program which would provide information related to core principles on the cerebellum and its functions and provide students with the foundation necessary to produce basic neuro-anatomical correlations no matter the chosen specialty later in their education. The program should provide the adequate amount of material to be useful to both early studies and future clinical application.
One other area missing from any of current programs was a section on the dimensionality of the cerebellar cortex cells. The intent of the program is to create such an expression by relating the three-dimensionality of specific cell types and their functionality to the Purkinje cell outputs and their relation to deep cerebellar nuclei.
One of the limitations foreseen early in the project was the scope. Further study would have to be conducted later by the neuroanatomy program as to the effectiveness of the interactive program on one group over a period of four years. This would test the significance enduring understanding’s effectiveness to medical education. The intention of this project was to create a model useable in testing, and to evaluate its efficacy on each individual group.
The final presentation method is an interactive web-based program designed to provide multiple methods of engaging the medical student during study. The interactive program includes illustrations, diagrams, movie clips, 3D animations and stills, and interactive questions. The textual information from the syllabus and accompanying textbook for the neuroanatomy class provided the backbone for the images and content which was included in two different spaces within the program. The main bar provided the most important information to a general understanding of the neuroanatomical concepts. Information included in the bottom bar was designated as advanced information and often included concepts beyond the knowledge necessary to gain a general perspective of the subject. The media was then compiled in Adobe Flash CS3 for final output as an .flv file. Here the content was given designated sections to guide the user and content tabs to provide easier reviewing.
The content of the paper is organized based on chronology in the developmental and creation process. The first chapter is an introduction, including the goals and objectives, the intended audience, significance, limitations to the scope, and the paper’s organization. The second chapter is a review of the existing literature pertaining to enduring learning and cerebellar circuitry providing information on the interactive and visual resources currently available in neuroscience pertaining to the cerebellum. The third chapter addresses the methodology used to design, create, and implement the program including the software used. The fourth chapter is an analysis of data from evaluations and testing done on the program’s effectiveness. The fifth and final chapter concludes the paper and includes recommendations for further study.
Review of the Literature
Introduction and Interactive Programs in Medical Education
The progress of educating and teaching in medical school can be painfully slow. Some critics question whether it is even changing at all from year to year. Hewitt states, “It is probably fair to say that most people do not see the field of education advancing at the same rate, or in the same disciplined fashion, as the field of medicine “(Hewitt 161). Yet some believe learning can be more efficient and enjoyable in future classrooms, but technology and computers access needs to play a central role (Hewitt 161).
The area of computer assisted learning has been heavily debated for years. In 2001, Greenhalgh noticed this emerging form of teaching through an enhanced learning style. She stated the use of computer assisted learning,
“…is inevitable. Individual lecturers and departments are already beginning to introduce a wide range of computer based applications, sometimes in a haphazard way. Planned and
coordinated development is better than indiscriminate expansion” (Greenhalgh 40-41).
Computer assisted learning helps to provide multiple methods of presentation of material. Within a computer interactive the teacher can blend video clips, games, quiz questions, clinical correlations with informational content and provide a diversity of learning styles (Lujan and DiCarlo 14-5).
Another reason for medical educational difficulties is a lack of defined learning styles and an understanding of the content necessary for proper application. Since medical students represent such a broad spectrum of ages, cultures, experience levels and ethnicities it is hard to limit an education to one method. Lujan and DiCarlo define a learning style as “ the complex manner in which, and conditions under which, learners most efficiently and most effectively perceive, process, store, and recall what they are attempting to learn” (13). Knowing this allows teachers to become more cognizant of medical students’ needs and hopefully find effective ways to implement such styles, to teach concepts more effectively and promote better learning (Lujan and DiCarlo 14-5).
Enduring Understanding Principals
One suggested learning style to change medical education comes from Amy Haddad, who believes teaching using the principles of enduring understanding can help medical students to not only possess knowledge appropriate to novel text but also to have the ability to reflect on their knowledge and put it into practice in the appropriate setting (Haddad 73).
“Like people in other design professions, such as architecture, engineering, or graphic arts, designers in education must be mindful of their audiences. Professionals in these fields are strongly client-centered. The effectiveness of their designs corresponds to whether they have accomplished explicit goals for specific end-users. Clearly, students are our primary clients, given that the effectiveness of curriculum, assessment, and instructional designs is ultimately determined by their achievement of desired learning. We can think of our design, then, as software. Our courseware is designed to make learning more effective, just as computer software is intended to make its users more productive”(Wiggins and McTighe 13).
Such statements provide the basis of enduring understanding. The concept was developed by Grant Wiggins and Jay McTighe in 1998 in the publication
Understanding by Design. Enduring understanding is defined as “the specific inferences, based on big ideas that have lasting value beyond the classroom” (Wiggins and McTighe 342). The core principles of enduring understanding are: defining the concepts and ideas, determine the main objectives of the course, decide what is worth remembering, establish transferrable knowledge across multiple skill areas, and choose essential ideas to the discipline at hand.
To better elaborate the principals toward which to determine what enduring concepts are, we break them into a few key objectives. First, enduring understandings are core concepts requiring overarching comprehension. They give meaning to concepts and importance to the facts at hand. They are usually concepts often misunderstood and requiring “uncoverage” yet are transferrable to other areas and topics. These principles would also provide a foundation for basic skills within which other information can be built upon and require a solidified foundation for optimal learning. For these principles to exist there must be six facets of understanding involved which offer a blueprint for uncovering the necessary objectives to a lasting teaching style: explanation, interpretation, application, perspective, empathy, and self knowledge. (Wiggins and McTighe 44-62)
The first facet, explanation requires “sophisticated and apt theories and
illustrations, which provide knowledgeable and justified accounts of events,
actions and ideas” (Wiggins and McTighe 85). Thusly, understanding requires not just knowledge of specific facts but a true ability to make inferences about a concept without specific rules or theories. Illustrations accompanying these texts, therefore, should be equipped to handle not just specific concepts within an area, but an application to the concept as a whole, allowing for broader applications. An evaluation of the current set of images available to students will be evaluated in the fourth chapter of this paper.
The second facet, interpretation is defined as “interpretations, narratives, and translations that provide meaning” (Wiggins and McTighe 88). The challenge presented to interpretation is to bring text to life, by having explanations and visuals to crystallize relationships with logically defensible concepts of a subject. Interpretations require solidified knowledge and a recall of the concept the student can be confident in (Wiggins and McTighe 90). Medical students therefore need the confidence not only to know a subject, but also to interpret its uses. The difficulty for the medical educator is to provide a student with these tools. Barker and Olson found in medical school such confidences to be crucial to medical education and that decreased scores can occur when a student lacks orientation and application (Barker and Olson 5).
The third facet, application, requires “the ability to use knowledge effectively in situations and diverse realistic contexts” (Wiggins and McTighe 92). Here, the student needs to be able to apply knowledge to a specific context. In this case effective use of skills would be application in a clinical setting. In the current structure of medical education, students have difficulty applying knowledge and half of them don’t have the necessary knowledge readily available in a clinical setting (van Hell 831).
The fourth facet, perspective, improves the student’s ability to have critical and insightful points of view on a subject (Wiggins and McTighe 94). Many medical educators can find difficulty having a student grow beyond repeatable knowledge to making examinations greater than the criteria they are being taught. Teachers need to foster the self-education process and supply instruments of clinical knowledge which can support analysis of a situation and reflection on current methods (Benini 14).
The fifth facet in enduring understanding is empathy. Empathy requires a person to understand another’s emotions and worldviews. Application of such knowledge allows for insight and a better understanding of the fourth facet, perspective (Wiggins and McTighe 98). Growth within empathy allows for
application in a clinical setting, another factor to what is lacking in earlier descriptions by van Hell.
The sixth facet is developing self-knowledge. Medical students need the ability to determine what they know and what they need to learn. Often within any educational setting the most common method to test such things is through assessment. Assessment allows the students to test their own knowledge and question their results. More often than not, though, teachers provide little quizzing before students are expected to perform on tests of large sectional knowledge (Wiggins and McTighe 98).
Using the principles of the six facets of knowledge we can then break down the best designs into those which are both engaging and effective. Engaging designs allow diverse learners to be energized, fascinated and provoked. Effective designs help learners to become more competent and productive, and provide engaging intellectual content which increases retention and speeds productivity (Wiggins and McTighe 195).
THE BASICS OF THE CEREBELLUM
Neuroscience abounds with textual resources on the anatomy and functionality of the cerebellum. Two major educational resources on the cerebellum are Purves Neuroscience, and Kandel, Schwartz and Jessel’s Principles of Neural Science. In this next section, I identify the important the important information to be provided within the interactive program, and describe the current information on the cerebellar anatomy, cerebellar cellular construction and its functional divisions.
The cerebellum is one of the most studied regions of the brain. Its placement and positioning in the brain gives it clinical significance and functionality in initiation, coordination, learning, the execution of movements and posture. It is located posterior and dorsal to the cerebrum and overlies the brainstem being separated medially from it by the fourth ventricle. It is also covered superiorly by the tentorium cerebelli. The primary function of the cerebellum is to regulate motor error between intended and actual movement and send signals to either correct for or reduce such errors (Adelman 321).
The cerebellum can be divided into three anatomically distinct regions respective medial to lateral: the vermis, the intermediate and lateral portions of each hemisphere. The main blood supply for the cerebellum is received through the vertebral-basilar arterial system, which is a posterior projection of the circle of Willis (Kandel Schwartz and Jessell 834).
On the surface of the cerebellum are some functionally separate and clinically
important subdivisions. Major external cerebellar structures include: the flocculi and nodulus, the brainstem, the cerebellar peduncles, the cerebellar tonsils, the folia, and the vermis.
The flocculi are a set of tufts of cerebellar parenchyma on either side of the
brainstem. Along with the nodulus, these structures comprise the floculonodular lobe which is closely associated with the vestibulocerebellum and is a relay for inputs from the vestibular nuclei (Purves 477-78).
The brainstem comprises the midbrain, pons, and medulla oblongata and is
connected to the cerebellum via the cerebellar peduncles. There are three separate cerebellar pathways into the cerebellum via the brainstem, the superior middle and inferior cerebellar peduncles, which connect the cerebellum to the other parts of the central nervous system. The superior cerebellar peduncles, also known as the brachium conjunctivum, are almost entirely made up of efferent fibers leaving
the cerebellum. The middle cerebellar peduncles or brachium pontis contain only afferent axons coming from the neurons of the contralateral basal pons. The inferior cerebellar peduncles originate in the medulla oblongata and contain mostly afferent projections with small amounts of efferent projections (Purves 477-78).
The cerebellar tonsils or amygdaline nucleus lies on the inferior-medial aspect of each hemisphere near the midbrain. They are clinically relevant as they are centrally located near the fourth ventricle and grow or abnormality can cause blockage of CSF in the brainstem. The folia are external structures characterized by narrow parallel ridges looking like pages of a book or “leaves” and give the cerebellum its extensive surface area. The vermis is located on the midline of the cerebellum and is a worm like structure that separates the hemispheres. It contributes to proprioception and is concerned with regulating eye and proximal muscle movements (Purves 476-77).
Internally, the cerebellum can be separated into four paired deep nuclei: dentate nuclei, emboliform nuclei, globose nuclei and fastigial nuclei. The dentate nucleus is the largest of the four in humans and receives most of its projections from the cerebrocerebellum and therefore effects motor planning. The emboliform nucleus is paired with the globose nuclei and is called the interposed
nuclei. The interposed nucleus receives connections from the spinocerebellum and effects motor execution by connecting to the brainstem and motor cortex. The fastigial nucleus also receives input from the spinocerebellum and thusly effects motor execution. The fastigial nucleus is often difficult to view grossly (Purves 480-1).
Cerebellar Cortex Anatomy
The cerebellum “constitutes only 10% of the brain but contains more than half of its neurons” (Kandel Schwartz and Jessel 832). The reason for its great collection of neurons is its broad surface area and thus widespread cortex. When viewed in cross-section, the cerebellar cortex can be separated into three distinct regions- the molecular layer, the Purkinje-cell layer, and the granular layer (Bear 558-59).
The outermost layer of the cerebellar cortex is the molecular layer. It contains the cell bodies of stellate and basket cells, which inhibit Purkinje cells. Stellate cells, called such for their star-like appearance, are a type of local interneuron which receives their input from parallel fibers. The other type of local interneuron in the molecular layer is the basket cell. It modulates a string of Purkinje cell bodies
as it wraps its axonal projections around the Purkinje cell bodies in a basket-like fashion. The only excitatory projections within this layer are granule cell axons called parallel fibers. These parallel fibers run parallel to the fanned distribution of Purkinje cell dendrites along the long axis of the folia (Adelman 321-25). Beneath the molecular layer is the Purkinje cell layer. The only cell bodies contained within this layer are the Purkinje cells. Purkinje cells are the only source of outgoing signals from the cerebellar cortex. Their enormous dendritic trees are flattened into a single plane, running perpendicular to the long axis of the folium. This orientation allows for integration of large amounts of granular cell (via parallel fiber) signals (Brodal 310-11).
The deepest layer of the cerebellar cortex is the granular cell layer. Within this layer are the cell bodies of the Golgi cell, and granular cells. Golgi cells receive their inputs from within the molecular layer. The Golgi cell dendrites receive excitatory influences from parallel fibers which receive their signaling from granular cell bodies. The Golgi cell provides a feedback loop to the granular cell by extending axons back to granular cells and producing an inhibitory influence on granular cell signaling (Manto 8).
Inside the molecular layer are two other extensions from the deep cerebellar nuclei: climbing fibers and mossy fibers. Together they provide all of the afferent signaling entering the cerebellar cortex. Mossy fibers mediate graded information about movement’s localization and proprioception due to their numbers in the lower granular cell layer. Mossy fibers also provide excitatory influence to the granular cells. Climbing fibers on the other hand provide
information about movement errors directly to the Purkinje cells through a series of complex spikes. These direct connections are provided by the climbing fibers ability to climb the Purkinje cell and wrap around their dendrites like vines. It is believed these signals to the Purkinje cell will alter the long term interaction of Purkinje cells with mossy fibers indirect actions (Brodal 312).
Functional Divisions and Pathway Projections
The circuitry of the cerebellum can be divided into two categories: afferent and efferent connections. Afferent connections involve the fibers entering the cerebellum via the peduncles and terminate in both the cerebellar nuclei and cerebellar cortex. Efferent connections involve the Purkinje cell axons leaving the cerebellar cortex and provide connections to portions of the motor cortex and descending pathways. The afferent and efferent projections of the cerebellum can further be divided into the three functionally separated portions of the cerebellum: the spinocerebellum, the cerebrocerebellum and the vestibulocerebellum (Adelman 324-26).
The oldest developmental division of the cerebellum is the vestibulocerebellum or floculonodular lobe. “It is the most primitive part of the cerebellum, appearing first in fishes…” (Kandel Schwartz and Jessell 834). It receives information from the vestibular semicircular canals, which provides a motional sense relating body and head position to gravity. The major vestibulocerebellar afferents come from the vestibular labyrinth and the vestibular nuclei by way of the inferior cerebellar peduncles. The major vestibulocerebellar efferent’s project back to the lateral, medial, and superior vestibular nuclei through same peduncle (Kandel Schwartz and Jessell 834).
The spinocerebellum is the next major division and can be subdivided into two major parts: the vermal portion (containing the fastigial nuclei) and the paravermal portion (including the emboliform and globose nuclei). The spinocerebellum provides information relating eye movements to centers of focus during head rotations. Afferent connections entering the cerebellum via mossy fibers provide fractured somatotopic information to the vermal and paravermal portions of the cerebellar cortex. The major spinocerebellar afferents collect in the contralateral ventral (anterior) spinocerebellar tract and ipsilateral dorsal spinocerebellar or cuneocerebellar tracts and make their way to the spinocerebellum via the inferior and superior cerebellar peduncles. The major spinocerebellar efferent connections can be seperated into the paravermal and vermal projections. Projections leaving from the paravermal lobe exit through the superior cerebellar peduncle and project to the contralateral cerebellum via the thalamus, and the ipsilateral rubrospinal tract. Efferents which leave through the vermal lobe travel through the inferior cerebellar peduncle and descend the ipsilateral vestibulospinal tract or the ipsilateral descending medial longitudinal fasciculus (Kandel Schwartz and Jessell 841-42).
The final and phylogenetically youngest division of the cerebellum is the cerebrocerebellum or neocerebellum. It was originally believed to be implicated in motor function but recently studies using fMRIs have shown it also has perceptual and cognitive functions involved in planning movement and evaluating sensory stimuli for action planning. Cerebrocerebellum afferents project from the contralateral inferior olive and the contralateral pontine nucleus and go through the middle and inferior cerebellar peduncles (Kandel Schwartz and Jessell 846).
The cerebellum is connected to the rest of the central nervous system via the cerebellar afferents of the brainstem. These connections convey information from the cerebral cortex, brainstem and peripheral nervous system to the cerebellum via one of three peduncles: the inferior cerebellar peduncles, middle cerebellar peduncles or superior cerebellar peduncles (Hendelman 148).
The first of these, the inferior cerebellar peduncle directs information from the medulla and brainstem to the cerebellum. The pathway connects information of the ipsilateral posterior (dorsal) spino-cerebellar pathway, the ipsilateral cuneo- cerebellar pathway and the olivo-cerebellar pathway to the cerebellar cortex. It also contains some afferent and efferent projections to vestibular nuclei (Hendelman 148).
The middle cerebellar peduncle is influenced by multiple portions of the cerebral cortex the cortico-pontine pathways. All of the middle cerebellar peduncles axons are afferent and are coming from neurons of the contralateral basal pons within the internal capsule via the pontine nuclei. They provide information relating to motor commands and intended motor movements (Hendelman 148).