Getting physical with medical education: Exercise based virtual anatomy review classes for medical students

Abstract

The benefits of regular physical activity are well known. Yet, few studies have examined the effectiveness of integrating physical activity (PA) into curricula within a post-secondary setting. To investigate the incorporation of PA into medical curriculum, we developed a series of optional exercise-based review sessions designed to reinforce musculoskeletal (MSK) anatomy course material. These synchronous sessions were co-taught by a group fitness instructor and an anatomy instructor. The fitness instructor would lead students through both strength and yoga style exercises, while the anatomy instructor asked questions about relevant anatomical structures related to course material previously covered. After the sessions, participants were asked to evaluate the classes on their self-reported exam preparedness in improving MSK anatomy knowledge, PA levels, and mental wellbeing. Thirty participants completed surveys; a majority agreed that the classes increased understanding of MSK concepts (90.0%) and activity levels (97.7%). Many (70.0%) felt that the classes helped reduce stress. The majority of respondents (90.0%) agreed that the classes contributed to increased feelings of social connectedness. Overall, medical students saw benefit in PA based interventions to supplement MSK course concepts. Along with increasing activity levels and promoting health behaviours, integrating PA into medical curriculum may improve comprehension of learning material, alleviate stress and foster social connectivity among medical students.

Key Words: Medical education; Musculoskeletal; Anatomy; Exercise; Online learning

Core Tip: There is a paucity of evidence on the integration of physical activity (PA) with post-secondary curricula. The current study aimed to investigate the effectiveness of exercise-based review sessions in reinforcing musculoskeletal (MSK) anatomy course content. It was found that overall, medical students saw benefit in PA based interventions to increase understanding of MSK concepts, reduce stress and increase activity levels. Therefore, integrating PA into medical curricula may not only supplement learning, but also promote healthy behaviour and supplement both physical and mental wellbeing.

INTRODUCTION

It is well-established that leading an active lifestyle is associated with physical and mental health benefits. Learning environments can promote movement behaviours through integrating physical activity into curricula[1]. Several studies have demonstrated successful strategies to encourage movement through integration of activity into core curriculum, such as mathematics and literature, which have also resulted in improved overall academic performance[1,2]. Most of the work advocating for active curricula has focused on younger learners, but these findings could extend to older student populations as well. Medical students, in particular, are at an increased risk of excessive sedentary behaviour and do not meet physical activity guidelines, spending a significant amount of time seated in academic settings[3].

The incorporation of physical activity (PA) learning strategies integrated with curricular content may encourage movement behaviours among medical students while simultaneously reinforcing related course concepts. This integration of learning strategies is supported by the Experiential Learning Theory, which when effectively integrated the learner is able to construct knowledge and meaning from real-life experiences[4,5]. The fundamental subject of anatomy is an opportune area to introduce exercise-based content delivery in medical curricula as certain anatomical concepts can be reinforced with movement and practical application. Bentley and Pang[6], developed a learning session that guided yoga practitioners through five yoga poses while simultaneously discussing the related bones and muscles of the lower extremity. After the session, 76.4% of the participants were able to apply the anatomical information they learned to their yoga practice. Similarly, McCulloch et al[7] found that integrating yoga and Pilates with anatomical instruction resulted in medical students increasing their anatomy comprehension, physical awareness, and relaxation and well-being.

Goal of innovation

The goal of this innovation was to develop a series of exercise-based review classes, that integrate musculoskeletal (MSK) curricular concepts to aid in preparation for anatomy examinations. We also aimed to explore the perceptions of participating undergraduate medical students to evaluate the impact of these physical activity-based review sessions on self-reported exam preparedness, activity levels, mental wellbeing, and social connectedness.

EXERCISE-BASED REVIEW SESSIONS

Three exercise-based review sessions were developed by a medical student certified as a healthy adult group fitness instructor in collaboration with anatomy instructors. Two sessions were circuit strength style sessions and the third was a yoga inspired session. All sessions targeted the entire body. Each circuit consisted of three exercises, which were performed twice. Each exercise, within the circuit, was timed or performed for 15 repetitions. During each session, students were guided through exercises by the instructor while the professor questioned them and discussed relevant MSK anatomical concepts. For example, one circuit consisted of squats, Romanian deadlifts, and standing lateral leg raise. During squats, the fitness instructor would cue a squat while describing the correct form and then when the students were performing their repetitions, the anatomy instructor would ask questions such as, which muscle is the prime mover, what type of contraction is the muscle performing, origins, insertions, and innervations. The yoga-style session allowed for a deeper dive into joint structures and the anatomy instructor questioned the students on passive and dynamic stabilizers of the joints being used during each pose. Examples of exercises and corresponding anatomy cues are outlined in Table 1.

Table 1 Examples of exercises performed and relevant anatomy cues.

Class format	Exercise	Anatomy cues
Bodyweight resistance exercise	Reverse lunge	Muscle: This exercise should be felt in the quadriceps, but what other muscle groups are being activated?
			Also working gluteal region, the hamstring group, and the medial compartment of thigh
		What are the three muscles that form the ‘glutes’?
			Gluteus maximus, medius, and minimus
			Innervation: What are they innervated by?
			Gluteus maximus: Inferior gluteal nerve
			Gluteus medius and minimus: Superior gluteal nerve
		Clinical correlate: What can result if gluteus medius and minimus lose their innervation?
			Trendelenburg gait/sign
Bodyweight resistance exercise	Push ups	Muscle: What muscles are being used when performing this exercise?
			Pectoralis and triceps muscle group
		Origin/ Insertion: Where do these muscles originate from and where do they insert?
			Pectoralis: Originates from the midline (sternum and clavicle) to attach at the humerus (pec. major) and coracoid process of scapula (pec. minor)
			Triceps: Originate on humerus and cross elbow joint to insert on olecranon process of ulna
				Exception: long head of triceps which originates from the infraglenoid tubercle of scapula and is the only one to cross the shoulder joint
		Innervation: What are they innervated by?
			Medial and lateral pectoral nerve (pectoralis)
			Radial nerve (triceps)
Yoga	Warrior two	Muscle: What muscles are holding the arms up in abduction?
			Deltoid and supraspinatus (first 15 degrees of abduction)
			Innervation: What nerves are they innervated by and what are the nerve roots:
			Deltoid: Axillary nerve
			Supraspinatus: Suprascapular nerve
			Roots: C5 and C6
		Clinical correlate: What would be the result of a C5, C6 nerve root lesion?
			Waiter's tip position: Adduction, medial rotation, extension and pronation of arm

Second year medical students at the Schulich School of Medicine & Dentistry at Western University were provided the opportunity to take part in optional exercise-based review sessions during their MSK block prior to their MSK anatomy examinations. In the first year, the review sessions were offered in-person, in a gym setting with weights. During the second offering, the exercises were modified to body-weight only exercises as the review sessions were offered online via Zoom (Zoom Video Communications, San Jose, CA, United States). The optional exercise review sessions were dispersed over a two-week period and were held following the completion of MSK anatomy coursework, including didactic lectures and laboratory sessions.

Evaluation of innovation

Exercise-based review session participants were invited to participate in a voluntary Qualtrics (Qualtrics, Provo, UT, United States) survey after the sessions were complete. To determine participants’ perceived physical activity levels, we asked students to indicate whether they were meeting Canadian adult physical activity guidelines of 150 minutes of moderate-intensity exercise per week, if they normally noticed a change in their activity levels during exam times, and to rate the sessions on their effectiveness in improving activity levels[8]. To determine participants’ perceptions about the sessions as an MSK study tool, we asked participants to rate the classes on their effectiveness in enhancing understanding of MSK concepts. To determine participants’ perceptions about the sessions’ impact on their mental well-being, participants were asked to rate their stress levels, feelings of social connectedness, and their overall enjoyment of the class. Survey items were presented as a statement with Likert style response options from 1 (strongly disagree) to 5 (strongly agree). For the analysis, strongly disagree/disagree, and strongly agree/agree were combined resulting in three categories (disagree, neutral, agree). Descriptive statistics were performed to present response frequency for each item. Ethical approval for this survey was obtained from the University of Western Ontario institutional ethics board, REB 116552.

PARTICIPANT FEEDBACK ON EXERCISE-BASED REVIEW SESSIONS

Thirty participants completed the surveys, of those, 13 participants (43.3%) attended only the virtual sessions; four (13.3%) attended only the in-person sessions; 13 (43.3%) attended both the in-person and virtual sessions. Of the 13 participants who had experience with both session formats (virtual and in-person), nine indicated a preference for in-person sessions (30.0%), one indicated equal preference for both (3.3%), while the remaining (n = 11, 10.0%) did not have a preference. Almost three quarters of participants (73.3%) reported that they did not regularly meet the recommended activity levels outlined in the Canadian Physical Activity Guidelines. Ninety percent of participants (n = 27) agreed that the exercise-based review classes increased their understanding of MSK concepts and helped with exam preparation (90.0%, n = 27). Most participants (96.6%, n = 29) agreed that the classes helped increase their activity level, while 70.0% (n = 21) reported agreement that the classes helped reduce their stress level (Figure 1). Ninety percent of participants (n = 27) agreed that the classes increased social connection among their peers. All participants (100%, n = 30) agreed that the classes were enjoyable and they would consider attending similar classes in the future. All items and frequency of responses are presented in Table 2.

Figure 1 Comparison of responses to key survey questions. A: Current activity levels in comparison to Canadian guidelines of 150 minutes per week where 733% of participants do not meet the recommendations; B. Activity levels were reduced further for 800% of participants during the exam period; C: Exercise review classes increased 96.7% of participants’ activity levels during the exam period; D: Exercise classes reduced stress for 700% of participants, 30%/0% reported no impact on their stress levels.

Table 2 Summary of survey responses presented as number of responses and percent of total responses, n (%).

Survey item	Participant response (n = 30)
Activity level	Meets Canadian guidelines	Does not meet Canadian guidelines
	8 (26.7)	22 (73.3)
Change in activity level during exams	Decreases	Stays the same	Increases
	24 (80.0)	3 (10.0)	3 (10.0)
Confidence in incorporating exercise counselling in your future practice	Not confident at all/Not very confident	Somewhat confident	Extremely confident/Very confident
	7 (23.3)	18 (60.0)	5 (16.7)
Feedback on class participation and understanding of MSK concepts
	Disagree	Neutral	Agree
Participating improved my understanding of MSK course concepts	0 (0.0)	3 (10.0)	27 (90.0)
Classes helped me feel prepared for my MSK assessments	0 (0.0)	3 (10.0)	27 (90.0)
I feel more confident integrating MSK concepts in my future practice and daily physical activity	2 (6.7)	3 (10.0)	25 (83.3)
Feedback on class participation and change in physical activity behaviours
	Disagree	Neutral	Agree
Attending class helped increase my activity level during exam period	1 (3.3)	0 (0.0)	29 (96.7)
Attending class helped increase my motivation to be physically active	1 (3.3)	3 (10.0)	26 (86.7)
I am more likely to try different exercise modalities after attending class	3 (10.0)	8 (26.7)	19 (63.3)
Feedback on class participation and stress related to exams and pandemic response
	Disagree	Neutral	Agree
Attending classes helped reduce stress during exam period	1 (3.3)	8 (26.7)	21 (70.0)
Attending classes helped with feeling connected to my classmates	0 (0.0)	3 (10.0)	27 (90.0)
Overall I enjoyed attending class	0 (0.0)	0 (0.0)	30 (100.0)
I would consider attending similar classes in the future	0 (0.0)	0 (0.0)	30 (100.0)

MSK: Musculoskeletal.

IMPACT OF INNOVATION

Students who participated in online and in-person exercise sessions to review MSK concepts provided positive feedback, and overall, suggested that this is an effective way to increase activity levels and improve their perceived comprehension of course concepts. Our findings align with previous work, which found that the incorporation of exercise activities increased anatomy knowledge comprehension[6,7]. Previous work has attributed the combination of non-traditional learning environments and hands-on activities to the effectiveness of these interventions[7]. In particular, Kolb’s Theory of Experiential Learning offers an explanation to the success of activity-based learning sessions. This theory centres on a process where learners first grasp new knowledge and then transform that knowledge by applying it to their own experiences. Learning is described as a dynamic cycle comprised of concrete experience, reflective observation, abstract conceptualization, and active experimentation[9]. Applying these concepts to our exercise-based review classes, students were first able to develop a concrete understanding of MSK anatomy through lectures and asynchronous content. Next, they reflected on the content and developed a conceptual framework during their in-person or virtual laboratories and through Socratic questioning of the anatomy concepts by their professors and teaching assistants during the sessions. Finally, during the exercise-based reviews, learners actively translated this knowledge and applied their understanding of nerve supply, muscles, and joints to movement of their own bodies. Thus, integration of exercise-based learning opportunities may be an effective way to implement active experimentation of anatomical knowledge.

Almost three quarters of participants (73.3%) reported that they did not regularly meet the recommended activity levels outlined in the Canadian Physical Activity Guidelines. This percentage increased through examination periods, with 80.0% of respondents reporting decreased activity levels during these times. These findings are similar to those reported by Blake et al[10] who, in a survey of medical students at a United Kingdom institution, found that most medical students did not meet physical activity guidelines, citing lack of time with study or placement schedules as perceived barriers to exercise. Incorporating physical activity into curricula could serve as a means to overcome these barriers and lead to change in physical activity behaviours of medical students. This is shown by our survey as 96.6% of participants reported that the exercise-based sessions helped to increase their physical activity levels during exams and 86.7% indicated an increased motivation to be physically active.

Decreased exercise is implicated in higher rates of depression and burnout among medical students, whereas increased physical activity is associated with enhanced coping mechanisms and overall mental well-being[11]. This was reflected in our findings, with 70.0% of participants endorsing that exercise-based learning helped reduce stress during examination their period. Similarly, 90.0% of respondents attributed class participation with an increased sense of connection to their classmates. As many medical programs are shifting to asynchronous delivery of content, the incorporation of exercise-based learning activities may help to foster community and build social connections between classmates in a more isolated learning environment.

Promoting exercise among medical students is especially important when considering their role in health advocacy as future physicians. It has been shown that personal physical activity practices of physicians influences their attitudes and recommendations of physical activity in clinical settings, resulting in active physicians providing more exercise counselling to their patients[12]. Incorporation of exercise-based learning sessions into medical curricula can enhance basic science knowledge and increase understanding of lifestyle medicine practices, which may lead to an increase in medical students’ confidence in counselling patients in exercise-based preventative medicine.

CONCLUSION

In conclusion, undergraduate medical students perceived exercise-based review sessions to be enjoyable, and found they increased their knowledge of core MSK concepts and exam preparedness. Additionally, integration of group physical activity into medical curricula can increase learner activity levels, which may result in alleviation of stress and promotion of socialization among students. Ideally exercise-based sessions should be integrated into the formal curriculum so all students benefit from the application of knowledge and review.