Internationally, higher education needs to both acknowledge and embrace the benefits of technologies to enhance not only the teaching and learning environment but also student experience. Indeed, teaching excellence at both undergraduate and postgraduate levels can be enhanced using technological advancements and technologies that simulate scenarios that are difficult to illustrate in a classroom. One rapidly expanding area in the educational setting is ‘mobile learning’. Mobile learning as suggested by Sharples (2000) is a learning process that can be applied across multiple contexts, through both social and content interactions, using personal electronic devices.

The value of mobile learning in higher education is critical for both students and academics on several fronts. Firstly, it is portable and flexible and provides instant access to information. Secondly, the freedom to directly access the information by the students significantly enhances the quality of students’ learning (Fitzgerald et al. 2012). Thirdly, the students’ environment together with the way the technology is used is fundamental to supporting students’ understanding of complex knowledge, academic performance and problem-solving skills of the spine and spinal deformities (Squire & Jan 2007). However, some academics are reluctant to implement mobile devices as a learning and teaching tool, because of a lack of motivation and appropriate training in the use thereof (Boude & Sarmiento 2017; Sánchez-Prieto et al. 2019). In addition to academics’ training, the implementation of mobile learning needs to integrate good pedagogical practice. This should aim for the pedagogical practice to minimise the negative effect of high consumption of mobile hours for leisure purposes and redirect them for more academic use (Alonso-Garcia et al. 2019).

Mobile learning is a form of immersive technology, which has several dimensions contained within it. Two of the main components are Virtual Reality (VR) and Augmented Reality (AR). Virtual Reality is defined as a technology that immerses the user inside a world of computer simulation that offers scenarios and activities that have a high level of realism (Lioce et al. 2015). However, with VR, it is important to acknowledge that whilst immersed in the programme the user cannot view the external real world (Chen & Tsai 2012). In contrast, AR, uses multi-touch interactive screens and simulations contained within mobile technology that significantly enhance the academic delivery of complex learning.

Figure 1 illustrates a simple diagram depicting the spectrum of reality. This ranges from the real environment at one end of the spectrum to the virtual environment at the other. Augmented Reality allows the user to view the real world, with virtual objects superimposed upon, combined and overlaying with the real world. This model of AR supplements reality but does not replace it (Andújar, Mejías & Márquez 2011).

Augmented Reality software together with a mobile interface contains ‘context-aware’ technology. Context-aware in this instance refers to the ability of the application to sense the physical environment and adapt its behaviour accordingly (Schilit & Theimer 1994). For example, interactive media can include text, images, audio, video, three-dimension (3D) models and animations as well as multiple-choice or open-ended questions. Images can be viewed through a mobile camera, which enables immersive, collaborative and situated learning experiences. For example, the marker in Figure 3A–D was used in our study to enable students to visualise the 3D spinal models as seen in Figure 2.

A marker-based AR technology used within this context is a physical trigger that when placed on a physical object enables the viewer to experience AR visualisations overlaid on the real object (Butchart 2011). This enables participants to be more ‘immersive’ and to interact with digital information that is superimposed within the physical object or environment (Dunleavy & Dede 2014). Clay (2011) suggests that this combination of immersive interactive learning used together with portable devices provides students with the flexibility of learning at their own pace. This flexibility has, in turn, enhanced students’ experience and acquisition of the performance skills required in real workplace settings, for example, clinical settings (Reznick & Macrae 2006).

Even though there are various examples cited of using AR as a learning and teaching tool in numerous disciplines such as science, mathematics, chemistry, education, biology and engineering, there is less literature on the use of AR in physiotherapy or other healthcare professional literature (Dunleavy & Dede 2014; Kamarainen et al. 2013; Qiu et al. 2021; Reeves et al. 2021; Supruniuk et al. 2020; Tan et al. 2012). Within healthcare higher education, there is an increased emphasis for students to use real-world experiences or tasks to enhance the quality of their learning and its application in clinical practice.

The relevance of using AR approaches to support and enhance student learning is threefold. Firstly, the three-dimensional rotating view and associated imagery of the mechanics of the spine provide students with an instantaneous overview of spinal function. Secondly, in our opinion, this approach facilitates and compliments problem-based learning as well as problem-solving techniques. This is because the student can actually see both the replicas of the ‘normal’ as well as spinal clinical conditions.

Within the field of physiotherapy, the understanding of the segmental movements of the spine is fundamental to successful clinical practice. Knowledge of the numerous coupling (accessory) motions involved within spinal movements is crucial for the physical assessment of patients, the diagnosis of pathological spinal disorders as well as the application of appropriate treatment approaches. However, students generally find it very difficult to visualise and critically analyse the accessory movements (glide and slide) of vertebrae during spinal movements (Noguera, Jiménez & Osuna-Pérez 2013). Furthermore, little is known about the effectiveness of AR for physiotherapy students in a laboratory-based environment and how AR compares to traditional learning within classroom or seminar settings. Therefore, the first objective of our study was to introduce and evaluate the use of a Vision-Based Augmented Reality (VBAR) mobile application to teach students the anatomy and accessory movements of the spine. Further, the second objective was to explore student experiences and engagement of VBAR by conducting a postlecture survey comparing VBAR to traditional teaching. It was hypothesised that the use of VBAR would increase students’ perceived level of understanding of the 3D structure, function and common pathology of the spine in comparison to the traditional method of teaching.

This exploratory study was evaluated using a post-intervention crossover design using two groups (groups 1 and 2) as shown in Table 1. Two tasks were taught to the students. Task (1) involved learning the anatomy of the spine. Task (2) involved learning the pathologies of the spine using both traditional and VBAR learning. The participants were final year BSc physiotherapy students (n = 74) with a mean age of 23 (±1.8). The content had not been taught to them before.

We hypothesised that the use of VBAR mobile application would increase students’ perceived level of understanding with the 3D structure, function and common pathology of the spine in comparison to the traditional method of teaching. A post-survey was carried out to evaluate outcomes associated with the students’ perceived level of understanding with the VBAR mobile application. We quantitatively measured (1) the students’ perceived level of understanding (based on questions Q1, Q2, Q5 and Q6) and (2) the students’ level of engagement (through questions Q3, Q4, Q7 and Q8).

In summary, our exploratory study sought to examine two hypotheses as stated at the beginning of our study. The results of our survey together with the written feedback indicated that the majority of students found that the VBAR mobile application enhanced their perceived understanding of the anatomy, function and pathology of the spine. We believe that this was achieved by students showing greater engagement with the 3D visualisation and interaction with the virtual spine. Twice as many students agreed that using the AR application was more helpful than traditional learning in clarifying any previous misconceptions that they had regarding the functional movement and neuroanatomy of the spine. The qualitative comments also indicated that students found the VBAR application was easy to use with instructions being clear and easy to understand.

Furthermore, we demonstrated that an inquiry-based learning approach used to engage students in problem-solving and experiential learning within the VBAR application improved students’ perceived subjective understanding of the learning content. Traditionally, spinal anatomy and its function have predominantly been taught using tactile objects such as physical 3D spine models and 2D images. We used inquiry-based learning to engage in problem-solving and experiential learning within the VBAR application, and this improved students’ understanding. Students agreed that the main advantage of using AR in spinal anatomy and pathology was the possibility of interacting with a virtual 3D spine structure instead of imagining the final structure through two-dimensional paper-based figures and pictures. The blending of e-learning contents together with the use of portable devices in classroom teaching offers students the flexibility of mastering core skills at their own pace. Using VBAR also enhanced students’ experiences and acquisition of performance skills that are required in real workplace settings (Clay 2011).

Previously, researchers have attempted to use AR in higher education settings. In the field of biosciences, AR enabled students to manipulate an object in 3D space, interactively exploring protein to protein interactions. Authors have found that this type of learning stimulates peer-to-peer discussions, thereby facilitating dialogic learning (Beltrame et al. 2017; García-Carrión et al. 2020). Similarly, Fombona, Pascual-Sevillana and Gonzalez-Videgaray (2017), in their study, found that an AR teaching approach promotes greater performance in student learning. According to them, this is linked to students’ enhanced creative thinking, motivational and recreational potential and the power of the immersive sense of experience.

In contrast, Cabero-Almenara et al. (2019) carried out a systematic review on the use of technology in higher educational setting, the summary of the findings are as follows: AR facilitates the understanding of complex phenomena, promotes contextualisation and enrichment of information, adapts to different types of intelligence, offers students the ability to interact by manipulating real objects, facilitates the development of a constructivist teaching or learning methodology, promotes the development of graphic skills through the perception of spatial content and 3D objects, it favors learning through practice (experiential learning) and increases motivation with very positive values of satisfaction, as well as improving academic results.

In the same way, our study also suggests that VBAR learning can act as an effective pedagogical tool to support student-centered learning, critical thinking and problem-solving skills. Conversely, Radu (2014) highlighted issues related to AR educational experiences, highlighting that the predominance of students’ ‘tunnel’ attention (tendency to focus on a single point of view), additional cognitive load, usability difficulties, inefficient integration in the classroom and student learning differences are appreciated. Although there are recent studies on projection-based AR in the human body (Ferdous et al. 2019; Hoang et al. 2017), the main limitation is this is more of a laboratory-based delivery of learning material. Because of the lack of studies using mobile AR specifically in physiotherapy students, our findings could not be directly compared with other studies.

Our study has shown that engagement with the VBAR application appears to be superior to traditional learning for helping students understand complex issues and prepare them for academic and clinical assessment (Q3 and Q7). With regard to the understanding of spinal anatomy, movements and pathology of the spine, most students agreed that VBAR was a powerful tool; the VBAR application helped them solve problems both individually as well as in a group. Furthermore, the use of VBAR through handheld technologies increased the ability of students to engage in interactive learning.

From the student comments, it was apparent that the AR app also improved the modes of communication amongst students. For example, the AR app enhanced students’ participation in meaningful scientific discussions and peer discussions. Furthermore, the findings also mirrored those of previous studies on student engagement with the use of AR technology in learning (Dunleavy & Dede 2014; Tang et al. 2020). This can be seen in a study by Tang et al. (2020) where they reported that technology-mediated narratives, as well as interactive, situated, collaborative problem-solving, afforded within AR simulation, were highly engaging in learning in higher education students.

The students’ qualitative comments further suggested that the VBAR intervention resulted in substantial student motivation as seen below. Our results are similar to the findings from Dede (2008), Dede and Richards (2012) where they demonstrated that the use of AR application within classroom teaching fosters increased motivation as well as increased learning:

Klopfer and Squire (2008) as well as other authors from diverse disciplines report that both students and teachers report high engagement in education as a result, not only of using handheld mobile devices but also by adopting and being involved in role-playing games. This significantly enhances students’ active involvement in solving authentic problems and engagement in learning complex tasks (Iatsyshyn et al. 2020; Sáez-López et al. 2020; Yu & Conway 2012).

In other questions (Q4 and Q8), both the VBAR and the traditional group had similar median scores. The scores for both types of learning were high, indicating a high level of engagement. The qualitative written feedback received from the large majority of students demonstrated that VBAR helped them prepare, both for academic work as well as their clinical reasoning skills. AR had an impact on both the students’ experience of learning as well as on their preparation for their assessment and was highly praised by most of the students. Some of the comments received can be seen below:

Our results reinforce Cochrane and Bateman (2010) notion that: ‘the pedagogical integration of mobile learning into a course or curriculum requires a paradigm shift on behalf of the lecturers involved, and this takes significant time’. These results demonstrate that an AR interactive learning environment enhances student-learning interest and promotes the learners’ level of engagement in learning complex issues.

The limitations of our study include the following:

The results of our post-intervention survey suggest that the integration of VBAR learning activities results in a number of learning gains relating to students’ perceived understanding of spinal anatomy, functions, pathology and deformities. Our findings further suggest that VBAR learning through student engagement within the classroom environment may improve healthcare students’ understanding of complex issues. Flexible learning through handheld mobile devices suggests that VBAR allows students to screen capture and record a video of their learning, which can be used as video notes for future reference and revision (Perry et al. 2008). This type of VBAR learning through student interactions in group work appears to facilitate enhanced communication between students and their peers (Tang et al. 2020). The findings from our exploratory study suggest that physiotherapy students subjectively perceived that using VBAR aided them in having a better understanding and learning of the course content compared to the traditional learning group.

Our study has only focused on the immediate perceived learning effects of VBAR. We intend to evaluate the longer-term learning effects of using VBAR within a Cognitive Load Theory (CLT) approach.