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Personalized augmented reality for anatomy education

Article  in  Clinical Anatomy · December 2015

DOI: 10.1002/ca.22675

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7 authors, including:

Meng Ma Anna Maria von der Heide

Technische Universität München Ludwig-Maximilians-University of Munich
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Jens Waschke Nassir Navab

Ludwig-Maximilians-University of Munich Technische Universität München
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1. INTRODUCTION

The General Medical Council recently proposed standards for effective teaching and learning of

medical students (Council & General Medical Council, 2009). They stated that: “...medical

schools should take advantage of new technologies…. to deliver teaching.” Augmented reality

(AR) research has matured to a level that its applications can now be found in both mobile and

non-mobile devices (Bacca et al., 2014) and research on AR has also demonstrated its extreme

usefulness for increasing student motivation in the learning process (Chang et al., 2014; Di Serio

et al., 2013). Providing adequate learning experience to different learners is a challenging issue

as the learning system generally does not adapt content to suit individual learner needs.

Personalization for promoting a multimodal learning environment is also a growing area of

interest, such as the development of user modeling and personalized processes which place the

student at the center of the learning development.

In today’s medical schools students are required to understand both function and spatial

context of human anatomy. Traditional medical education learning is classified into three

categories: cadaver, model, and book-based. The cadaver-based learning has seen decline due to

practical and cost issues. As a result, anatomical education has shifted towards physical, diagram

and image models. However, some drawbacks exist with these learning paradigms. For example,

it is difficult to interpret the spatial and physical characteristics of anatomy by observing two-

dimensional images, diagrams, or photographs. Many physical models also lack detail levels to

fully understand the specific anatomy.

In the advent of the plethora of exciting technological advancements there should be no

reason not to include these for the creation of new education paradigms for medical learning. By

combining computer models of anatomical structures with custom software we can showcase to
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students new ways of interacting with anatomy that could not be achieved during cadaveric

dissections or in static images and diagrams for increasing their learning satisfaction (Bacca et

al., 2014; Ma et al., 2012; Nmc, 2014).

E-learning is commonly used today. A large number of case databases, atlases for medical

experts, and atlases for non-experts exist. These resources are very valuable and are more

interactive and interesting than textbooks; however with the disadvantage of having users still

mentally map/link anatomy to their bodies. The personalization in E-learning systems has been

the subject of much recent research and allows teachers to select personalization parameters and

combine them flexibly to define different personalization strategies according to the specifics of

the courses.

Many commercially available systems use virtual reality (VR) for medical education and

psychomotor skills training. These systems have indeed proven to be valid and are of use in

clinical training (Lewis et al., 2011; Thijssen et al., 2010; Van Dongen et al., 2011). In addition

to the advantages of VR, AR systems also have the advantage that information can be embedded

and/or superimposed upon reality. This allows for a more close-to-reality presentation of medical

knowledge and offers opportunities for more interactive learning. The user can also spatially

relate virtual objects to the reality.

In medical training, some AR systems use a head-mounted display for visualizing information

in-situ. Davis (2002) presented a system which augmented a 3D model of the anatomical airways

onto a patient phantom using a head-mounted display (HMD). Another system that used a HMD

to visualize human anatomy onto a phantom has been developed by Juan et al. (2008). Their

system allowed students to open up the abdomen of the phantom, visualizing different organs

directly on the phantom. The main advantage of HMDs is that they allow the user to freely move.
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State-of-art HMDs however have

several important drawbacks: they

are fragile, require technical

support upon use, are large and

heavy, and often cause simulator

sickness. Hence, they are not well

suited for medical education.

AR in formal and informal

learning environments with an

emphasis on affordances, usually
utilizes context-aware technologies,
Figure 1. Personalized magic mirror system for anatomy learning. A
sensor tracks the user positions in real-time, and contextual in-situ
visualization algorithms enable the augmentation of organs and
muscles directly onto the user body.

which enable participants to interact with digital information embedded within the physical

environment (Dunleavy et al., 2013). The AR system presents digital media to learners after they

point the camera at an object (e.g., QR code, 2D target) and creates immersive learning

experiences with the physical environment, providing educators with a novel and potentially

transformative tool for teaching and learning (Dede, 2009; Johnson et al., 2011). In medical, an

AR system for patient-doctor communication has recently been presented (Ni et al., 2011). This

system used a hand-held projector to project anatomy onto the skin of the patient. While this

system is relatively inexpensive, it could only display anatomy which is close to the skin in

correct perspective. Furthermore, it did not automatically track the position of the projector and

the patient. The doctor must then figure out manually how to position the projector and the

patient in such a way that the anatomy is augmented correctly.

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An alternative are “magic mirrors”. Here the user stands in front of a screen and via a camera,

the image of the user is shown on the screen such that it acts like a mirror. While such a system

restricts the motion of the user, it allows for an inexpensive and robust solution that is better

suited for medical education. The concept of an AR magic mirror has been shown previously,

mainly for advertisement and marketing. Previous systems augmented onto the user virtual shoes

(Eisert et al., 2008; Luh et al., 2013), shirts (Ehara et al., 2007) and knight’s armors (Fiala, 2007).

For tracking the position of the user, previous systems have used tracking markers (Eisert et al.,

2008; Fiala, 2007; Luh et al., 2013) or a tracking shirt with a rectangular highly textured region

(Hilsmann et al., 2008). For shoes, a vision-based approach has been presented (Eisert et al.,

2008).

Contributions: Contrary to all of the above solutions, our AR magic mirror (Blum et al., 2012)

allows a view inside the user. The system could track the current user and modify the medical

datasets based on the user’s information (e.g., height, body size, gender, and age). Our system

inherently allows the user to directly map the anatomy onto their body. This opens interesting

possibilities for personalized AR for anatomy learning. Through the participation of 7 clinicians

and 72 anatomy students, two user studies were designed to respectively assess the precision and

acceptability of our magic mirror system for anatomy education in the classrooms of tomorrow.

2. METHODS

The interactive anatomy learning system which is presented in this paper is an augmented reality

magic mirror and has primarily been developed for medical anatomy education, museums, and

exhibitions. It focuses on bones and important organs of the thorax and abdomen. Figure 1

depicts the general view of the system, which includes a large display device and a Microsoft
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Kinect. The Microsoft Kinect contains both color and depth camera and is sold as an add-on for

the Xbox 360 video game console, taking gestures, color image, body movement, and voice as

game input. The user’s skeleton and personal information can be generated from the Kinect

sensor. The prototype of our magic mirror is largely based on a software framework that has

been developed for HMD-based AR. Our system prototype has a mirror-like effect to the user by

projecting a ‘looking glass’ on the user body. The system can currently provide AR in-situ

visualization, render skeleton from an original CT-volume, and showcase 3D models of organs.

2.1 AR in-situ visualization of human anatomy

For a personalized visualization of organs we employ the concept of a magic mirror. The camera

image is flipped horizontally and shown on the screen such that the user has the impression of

standing in front of a mirror. The system tracks all user movements using a depth camera and an

algorithm to detect the pose of the user from the depth image. This is realized using the

Microsoft Kinect which was originally developed to allow controlling computer games by

motion. Then, virtual objects can be added to the image of the real scene. By using the magic

mirror metaphor, the user is led to believe that he or she is able to look inside their own body. At

the same time, radiological information (CT data and a fully segmented dataset of cross-sectional

photographs of the human body) are displayed in real-time (Blum et al., 2012).

We augment a personalized visualization of a CT dataset onto the user. However as full CT

scans of any user are generally not available, we use the Visible Korean Human dataset (VKH),

which consists of a CT scan, an MR volume and a photographic volume which has been acquired

by stacking up cry sections. To allow a correct augmentation of the CT data, the gender, age,

body size and pose of the user has to be detected. This is performed based on the color image
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Figure 2. (a-b) The inaccurate Kinect skeleton, in yellow, compared to the improved Kinect skeleton positions in
red. (c) CT data from the Visible Human Korean showing the 5 landmarks from Kinect skeleton. (d) CT data
showing correctly the 5 landmarks + interpolated torso landmark using our method.
using the OpenBR library (Klontz et al., 2013) and the depth image using the NITE skeleton

tracking software. The corresponding CT volume is chosen and scaled to the size of the user and

augmented onto the user body. For visualization of the bones a transfer function is used as bones

can be distinguished easily in the CT volume based on their voxel intensities. For the organs a

segmentation of the VKH is used. The augmentation uses contextual in-situ visualization such

that the virtual objects are only shown through a circular window (see supplementary video 1).

This leads to a better perception of depth, compared to a simple augmentation of the whole CT.

The user could naturally turn around their body to check CT volume from different viewpoints

and put their right hand at different heights to select a body plane with corresponding anatomy.

2.2 Improvement of tracking and overlay accuracy

The skeleton output from Kinect limits the precision of the AR magic mirror applications. Thus,

our magic mirror augmentations would contain errors and users would easily distinguish

anatomical offsets on their body resulting in a poor anatomy learning environment. Alternatively,

we had considered projectors to display human anatomy and along with their existing limitations

the same inaccuracies would exist. Our aim was then to propose a method to correct for such
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overlay inaccuracies that could be translated to any magic mirror system worldwide. Together

with orthopedic surgeons, we have defined five bone landmarks that (i) users can easily identify

and touch while standing in front of the Kinect, and (ii) that are accurately and easily identified

in medical data such as CT (Meng et al., 2013). These are: left and right acromion, left and right

anterior superior iliac spine, and the manubrium (see Figure 2).

Prior to correctly using our AR magic mirror system, the users stand in front of the monitor

and we displayed virtual marks near the five bone landmarks. The users are asked to interactively

adjust the positions of the five marks to fit their own bone positions. In addition, the exact

locations in the VKH CT dataset of the five selected bone landmarks are known. A linear

interpolation was executed to estimate the torso point (i.e. a 6th landmark) in the CT volume to

improve the overlay. Then the scale factors and transformation matrix were computed to render

the anatomical image onto the user’s body. These landmark positions allow the deformation and

interpolation of the medical data correctly within the magic mirror and onto the human body,

resulting in a more precise augmentation. A user study involving surgeons and anatomy experts

confirmed our findings and will be presented in Section 3.

2.3 Personalized natural interactions & gaming

Gesture-based interaction: Medical volumes are usually visualized by showing slices that are

aligned with the axes of the volume. A volume can be seen as a stack of transverse slices starting

from the top and going to the bottom. When the system is in the transverse slice mode, the user

could move their hand up or down to choose the interesting slice image, respectively left or right

for the sagittal slice mode. The current slice is depicted on the right part of the monitor while a
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Figure 3. (Left) The organ explosion effect. Using the left hand, the user is able to focus height for the section they
are interested in. Organs at approximately the same height are then projected outwards. Using a spherical projection,
the organs are moved outward, creating the illusion of seeing them fly in front of the body. (Right) The Whack-An-
Organ game, in which the user is presented with questions regarding human anatomy and where the answers are
always organs or organ systems. Gaming interaction showcased here are: find the liver, to more complex knowledge
questions such as: select the organ that exchanges oxygen and carbon dioxide between air and blood.

yellow circle is augmented onto the user depicting the slice plane. The system can easily switch

slices between the CT and the photographic volume.

Organ explosion effect: In the AR learning environment, organ selection is a challenging task

as some organs hide behind others. The user can’t directly position their hand into their bodies

and to select the organ of choice. In engineering design, mechanical parts are drawn with the

innermost part at the center, while the others are moved some fixed distance outwards to display

all parts of the assembly that would otherwise be hidden. Inspired by this principle we designed

and developed an organ explosion effect (see Figure 3-left), which separates the organs. The

organ explosion selection employs a two-hand interaction method. Using the left hand, the user

is able to focus the height for the section they are interested in. Organs at approximately the same

height are then projected outwards. Using a spherical projection, the organs are moved outward,

creating the illusion of seeing them ‘fly out’ in front of the body. Lines are drawn to indicate the

original position of the organs. After separating the organs from each other, it is easy for the user

to select the organ of interest using their right hand. Another functionality of the organ explosion
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effect is allowing the user to rotate and observe the 3D organ models and perceive the spatial

relationship between them (see Supplementary video 2).

Serious gaming: Health education is a particular area where serious gaming is suited (Aubin et

al., 2012; Hannig et al., 2012). We developed a game for general users to learn basic anatomy

called Whack an Organ (see Figure 3-right). Our game is based on the idea of the classic arcade

games at carnivals, ‘Whack-a-Mole’. We implement a similar game idea using our system

framework. It is a combination of Whack-a-Mole and classical quiz games: the user is presented

with questions regarding human anatomy, and the answers are always organs or organ systems.

To answer the question, the user has to point to the location of the organ directly on their body.

The game then decides if the location is correct and awards points if so. Questions can come

from different question sets with varying difficulty, ranging from simple location questions:

where is the liver?, to more complex knowledge questions: which organ is infected if you have

Hepatitis? (see Supplementary video 3).

3. EVALUATION & RESULTS

As an augmented reality anatomy learning application, both accuracy and system usability are

very important prior to its translation in classroom. Firstly, we undertook one user study with

particular users having expert anatomy knowledge to evaluate if this system is precise enough for

anatomy learning. Secondly, another user study involving first year medical students took place

to verify the learning potential and acceptability of our technology as a compliment to atlas

textbooks in classroom.
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3.1 Assessing the magic mirror system precision and usability

Participants: Seven participants were included in this study (two surgeons and five final year

undergraduate medical students).

Analysis: a Likert scale was used which is a type of psychometric response scale often used in

surveys and the most widely used scale in survey research. When responding to a Likert

questionnaire item, respondents specify their level of agreement to a statement. The format of

our 5-pt Likert was: (1) strongly disagree, (2) disagree, (3) neither agree nor disagree, (4) agree,

(5) strongly agree.

To assess the precision of our personalized magic mirror we asked the participants to interact

with the system platform which integrates user-specific anatomical landmark selection.

Participants were asked to provide an estimated numerical offset, if any, on how far specific

bone landmarks or organs were with respect to their own body. For this, they interacted with the

magic mirror window, CT data, and used their own medical knowledge and expertise for

judgment. CT data was displayed in an interface depicting both transverse and sagittal planes,

and participants would quantify the offsets. If needed, a ruler was provided to assist them. The

anatomical targets during evaluation were defined as: the anterior superior iliac spine,

manubrium, heart, and liver. Results from this exercise are shown in Table 1, with offsets

measured in centimeters. Results from the user study show that the precision of user-specific

learning environment is on average 0.96cm.

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Table 1. Precision (in cm) of magic mirror system based on anatomical offsets

Anatomy Offset (Mean ± STDev)

anterior superior iliac spine 0.67  0.52

manubrium 0.67  0.75

heart 1.17  1.60

liver 1.33  1.21

The seven participants were then asked to judge the usability of the AR magic mirror system by

responding to the following questions: (i) is the overlay accurate w.r.t human body (ii) is the user

interface easy to use, (iii) is it fun to play, (iv) can it be used for medical education, and (v)

would it have stronger impact for medical education learning?

The Likert scale results for the first four questions are shown in Table 2.

Table 2. Likert scale results regarding magic mirror usability

Mean ± STDev

is the augmented reality overlay accurate w.r.t human body 4.00  0.89

is the user interface easy to use 3.67  1.03

is it fun to play 4.50  0.55

can it be used for medical education 4.17  0.75

For the last question regarding the impact of our technology, there was a unanimous response

that the AR magic mirror system should be considered as a potential platform to complement

existing anatomy learning tools inside anatomy classrooms.

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3.2 Assessing learning potential of the magic mirror system

Participants: 72 medical students from the ANONYMOUS Medical University, having an age

range between 21yrs and 28yrs, were included in this study. The distribution of gender was 38

male and 34 female. Their medical experience was: 50 participants did not have any expertise, 8

had paramedic training, 5 with healthcare training, and 9 with some other degree (e.g. biology,

chemistry, and therapy).

Analysis: Responses to questions were based on a four point Likert Scale: (1) strongly disagree,

(2) disagree, (3) agree, and (4) strongly agree. For statistical analysis, the response categories

were reduced to Yes/No: Yes (agree + strongly agree); No (strongly disagree + disagree).

The study procedure included every participant to use the personalized magic mirror system for

15 minutes and try all available system functions and games. Participants were then asked to

assess the learning potential of our technology by responding to the following questions:

Q1- is the system helpful for anatomy learning?

Q2- do you like to use the magic mirror?

Q3- is the presentation and visualization of CT volume acceptable?

Q4- do you like the AR view of 3D human anatomy?

Q5- what other information would you want to see from the 3D rendering? (Open question)

Frequencies (F) and percentages (%) of response on the first four questions are given in Table 3.

The questionnaire, focused on motivation and perception of the participants, showed statistically

significant differences of all the questions. Percentages confirmed how the fresh students accept

our magic mirror for anatomy learning.

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Table 3. Frequencies and percentages of response of the fresh medical student about the AR system

Q1 Q2 Q3 Q4

F % F % F % F %

Yes 62 86.1 60 83.3 68 94.4 66 91.7

No 10 13.9 12 16.7 4 5.6 6 8.3

The results of question 5 are depicted in Table 4. They indicate that the participants would

eventually like the current magic mirror system to evolve to one that includes the visualization of

complex anatomy models such as the vascular system, relations between different organs,

extremities, etc.

Table 4. Frequencies and percentages of new 3D anatomy expected by the 72 medical students

new 3D rendering functions F %

vascular system 19 26.4

relationship between different organs 13 18.1

extremities 10 13.9

landmarks 6 8.3

static AR view with their body 6 8.3

head/brain 5 6.9

muscle 5 6.9

others 5 6.9
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4. DISCUSSION

Education of anatomy is a challenging but crucial element in educating medical professionals,

but also for the general education of pupils or higher education (such as students of sports &

physiotherapy). The novelty of this work lies in the development of a personalized AR magic

mirror which provides intuitive visualization of realistic anatomical information directly onto the

user’s body and allows for natural gesture interaction. The personalized magic mirror prototype

has been integrated, by the authors of this paper, into the first-year anatomy classrooms at the

ANONYMOUS Medical University.

Results from the user studies demonstrated that the magic mirror system is precise enough for

the students to learn anatomy. We obtained additional feedback by the participants which is

summarized below:

o the precision is good.

o making the user touch anatomical landmarks is cool since this is the way it is done in

clinical practice.

o the AR view of the user body is great and helps the students link the knowledge onto the

real human body.

o voice command is a good idea but it is sensitive to the surrounding voice interactions of

the audience or users.

o could use a healthy patient CT or other imaging modality.

Figure 4 depicts the visualization of muscle anatomy of a human arm. The magic mirror was

embraced by the majority of the medical students in its current version. Based on our discussion

with them we found that the students really liked the AR visualization on their own bodies,
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Figure 4. Personalized muscle visualization of the user’s arm.

however they were not used to the natural user interface and gestures required for interaction. A

learning curve was necessary for them to appease initial frustrations they had when first using

our system.

One appealing feature of the system is that with the Kinect sensor we are using inexpensive

standard hardware. In the future such a system could be made available to students or patients

who have to do rehabilitation exercises at home. In addition to the full system which uses a large

screen and stand, we also want to evaluate the benefit of making the system accessible to

students when they are at home studying.

We want to do this for two different reasons. First, there is a trend toward competency-based

education in medicine. Instead of defining a curriculum, learning outcomes are defined. Students

have to fulfill these learning outcomes. The advantage of competency-based education is that all

students will have the same competency in the end. A student who is less skilled has to take

more time to learn than a student who already has good skills. The second reason to develop a

distributed system is to collect user statistics. In future, students will learn fundamental concepts

related to medical education and surgical training. The magic mirror technology will be

compared to traditional learning platforms such as textbook, cadavers, etc. A study involving
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questionnaires and exams on simple anatomy or muscle will be conducted to assess the impact of

the magic mirror technology on student ability to learn via new technology, as well as, the total

time required for learning.

5. CONCLUSION

This paper presents a personalized augmented reality magic mirror system for anatomy education

purposes. Our system is certified accurate and useful enough for anatomy learning and the

majority of the medical students accepted the learning potential of the technology. The academic

methodologies must be changed according to the advance of new technologies, but there is still a

long way for this. Considering the benefits of the personalized and interactive AR system for

motivation and perception of anatomy learning, new technologies can additionally be helpful to

facilitate autonomous learning and secondarily to reduce laboratory material and instructor costs.

Together with the anatomy community, we hope to initiate such discussions in integrating

exciting user-specific and gaming concepts within curricula via anatomy learning systems.

6. ACKNOWLEDGEMENTS

The datasets used for the augmented reality visualizations were used from The Visible Human

Project which is readily available online. We also used a simplified model from a detailed

commercial anatomy set (Anatomium 3D by CF Lietzau 3D Special Service).

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