Investigating Mental Rehearsal's Applicability in Guiding Independent E-learning of Eye Examination Skills During the Pandemic – Part II (IMAGINE-II)

Investigating Mental Rehearsal's Applicability in Guiding Independent E-learning of Eye Examination Skills During the Pandemic – Part II (IMAGINE-II) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Investigating Mental Rehearsal's Applicability in Guiding Independent E-learning of Eye Examination Skills During the Pandemic – Part II (IMAGINE-II) CHEE CHEW YIP, ZHENG XIAN THNG, YAN YEE HAH, ANDREW SHI-JIE YAP, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6314150/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Guided Mental Rehearsal (GMR), underpinned by the Theory of Motor Simulation, supports the learning of psychomotor skills. We hypothesized that (a) GMR would be comparable to Guided Physical Practice (GPP) for learning Pupillary Examination (PE), and (b) Mental Imagery (MI) ability would improve with GMR practice. Methods This assessor-blinded, randomized controlled study included 53 pre-clinical students (GMR n = 26, GPP n = 27), with sample size calculated from pilot data (n = 46, power = 0.81, alpha = 0.05). On day 1, baseline MI ability was assessed, followed by PE instruction. Practices (GMR or GPP) were conducted at weeks 1 and 3. PE performance and MI ability were reassessed using a checklist score sheet (month 1) and the Movement Imagery Questionnaire–3 (month 2). Results Data is presented as median with interquartile range. The Mann-Whitney U test showed no significant differences in PE performance between the GMR and GPP groups at months 1 (35.00 [14.00] vs. 33.25 [12.00], p = 0.91) and 2 (40.00 [10.50] vs. 36.42 [12.00], p = 0.50). In the GMR group, PE scores improved from month 1 to 2 (35.00 [14.00] vs. 40.00 [10.50], p = 0.02, Wilcoxon Signed-Rank test). The Friedman test, followed by a post-hoc Wilcoxon Signed-Rank test with Bonferroni adjustment, indicated improved MI ability across baseline, 1 month, and 2 months (Kinaesthetic Visualization Score: 22.00 [8.00] vs. 23.00 [7.00] vs. 24.00 [6.00], p < 0.01; External Visualization Score: 24.00 [5.00] vs. 25.00 [6.00] vs. 26.00 [4.00], p = 0.36), which was not observed in the GPP group. Conclusions Repeated GMR was found to be non-inferior to GPP for learning PE, and MI ability improved with deliberate GMR practice. GMR may serve as a cost-effective, resource-independent adjunct for acquiring clinical examination skills. Mental Rehearsal Clinical Examination Deliberate Practice Figures Figure 1 Background The COVID-19 pandemic disrupted the traditional in-person teaching models for medical education (Ahmed et al., 2020 ) in favour of social-distancing compatible online-learning (Stoehr et al., 2021 ). However, the resultant lack of in-person repetitive practice and immediate feedback posed a major obstacle to the teaching and mastery of clinical examination (CE) skills, as outlined by the Deliberate Practice Theory (Ericsson, 2004 ). One possible solution is the use of Mental Rehearsal (MR). MR involves retrieving perceptual information from memory to mentally visualize the steps of a motor task, allowing cognitive rehearsal without physical movement (Martin et al., 1999 ). MR technique is based on the Motor Simulation Theory, which suggests that MR activates similar neurocircuits as physical practice (Jeannerod, 2001 ). It is widely used in sports (Di Corrado et al., 2020 ; Lin et al., 2021 ) and surgical training (Souiki et al., 2021 ; Williams et al., 2012 ). However, its applicability in undergraduate training is underexplored. To support novices lacking schematic knowledge and prior perceptual information, Guided Mental Rehearsal (GMR) was introduced, allowing experts to guide MR of psychomotor skills (Kosslyn et al., 2001 ; Mahoney & Avener, 1977 ). GMR is a cost-effective and convenient learning method, and may thus be worth promoting for teaching CE to undergraduates, especially in a pandemic context. The IMAGINE study demonstrated GMR's effectiveness in teaching medical students CE psychomotor skills in a single session (Ding et al, 2023 ). This raises the question: can GMR serve as a reliable method for developing competency through repetitive practice? Further investigation is needed in two key areas to advance theory and practice. Firstly, the IMAGINE study evaluated only a single GMR session and used peer-learning as the control group. Using Deliberate Practice Theory (Ericsson, 2004 ), we aim to investigate the potential of repeated GMR for skill mastery through repetitive practice. This longitudinal study assesses the effect of repeated GMR on skill acquisition and retention, reflecting real-life learning habits where learners engage in ongoing practice. We will also directly compare GMR with Guided Physical Practice (GPP), where learners perform CE on healthy simulated patients using GMR audio transcripts. Our primary hypothesis is that repeated GMR is non-inferior to repeated GPP for acquiring and retaining CE psychomotor skills, with the main outcome being CE performance during timed assessments. Secondly, it is important to assess whether MI is a trainable skill. Learners have varying baseline mental imagery (MI) capabilities, influenced by factors such as age, gender, and background experiences (Floridou et al., 2022 ). Those with lower MI ability may struggle to activate relevant neurocircuits (Jeannerod., 2001). However, evidence shows improved MI with repeated practice, even in patients with Parkinson's Disease (Maillet et al., 2015 ). Thus, our secondary hypothesis is that MI, like CE, improves with repeated GMR practice. The outcome will be quantitatively assessed using MI-related indices from the validated Mental Imagery Questionnaire-3 (MIQ-3) (Williams et al., 2012 ). Methods Setting and Design This study was conducted at the Lee Kong Chian School of Medicine (LKCSoM), Singapore, from October to November 2021. Ethics approval was obtained from the Nanyang Technological University Institutional Review Board. Written informed consent was obtained from participants above the legal age of 21, and parental consent was obtained for those below 21 years old. This longitudinal, randomized-controlled study compared the efficacy of repeated GMR (intervention) versus repeated GPP (control) in the E-learning of ‘Pupillary Examination’ (PE). Sample Size Calculation Sample size calculation was made by extrapolating the data obtained from the IMAGINE study (Ding et al., 2023 ). Using the Cliff’s Delta method for non-parametric data, the effect size for IMAGINE study was 0.850. Thus, for the IMAGINE-II study, a sample size of 23 participants per group was required to achieve a desired power of 0.080 with an actual alpha of 0.050. In anticipation for possible participant withdrawal during the study, a decision was made to recruit 20% more than the calculated required sample size of 46. Participants All second-year, pre-clinical medical students from the LKCSoM Class of 2024 were recruited, and 54 consented to participate. Inclusion criteria was the successful completion of the first year of undergraduate, pre-clinical medical training. Exclusion criteria was the possession of clinical experience or pre-clinical knowledge regarding Ophthalmology. This exclusion was declaration based. None of the participants declared attending any formal eye related teachings prior to this study. Participants were randomly assigned to the control (GPP, n = 27) or intervention (GMR, n = 27) group. Materials Intervention This study had four main types of learning activities. All learning materials were developed iteratively by senior Ophthalmologists who had completed core faculty development courses in assessment and had at least five years of teaching experience. Neuro-Ophthalmology Tutorial This was a 1-hour long face-to-face teaching on basic ocular anatomy and physiology related to PE. The purpose was to impart essential background knowledge to facilitate the subjects’ understanding of PE subsequently. Synchronous E-learning of Pupillary Examination via Google Drive (Alphabet Inc, Mountain View, California) Students watched an eight-minute-long instructional video of an expert explaining and demonstrating the steps of PE. Tutor-led Skill Demonstration with Physical Practice This 30-minute interactive session included a tutor-led demonstration of PE, followed by student-led physical practice with ad-hoc Q&A. The aim was to consolidate newly acquired knowledge, as the participants lacked prior ophthalmic background and clinical experience. GMR versus GPP Asynchronous e-learning was continued for the GMR group (n = 27). They listened to a six-minute audio recording of the content expert’s running commentary on PE of a normal patient. During the process, participants closed their eyes and attempted mental visualization of the steps described. This was repeated for 2 cycles over 15 minutes, inclusive of a 3-minute buffer time. The script for the running commentary is provided in Annex 1 . The control group (n = 26) underwent GPP of equivalent duration, allowing subjects to reference the printed transcript of the commentary ( Annex 1 ) and go through the steps at their most comfortable pace. All participants were prohibited from revisiting the instructional video and practicing independently outside of scheduled sessions. This practice was repeated once at weeks 1 and 3, as shown in Fig. 1 . Instruments Movement Imagery Questionnaire – 3 (MIQ – 3) This validated 12-item Questionnaire utilizes a 7-point Likert scale to quantitatively assesses one’s ability to ‘see’ (visual: first [internal] and third [external] person perspectives) and ‘feel’ (kinaesthetic) the mentally visualized motor processes.(Williams et al., 2012 ) This provides a surrogate measure for an individual’s ability to generate and control vivid images. The MIQ-3 can be found in Annex 2 . Clinical Evaluation eXercise (CEX) This six-minute timed assessment evaluated the participants’ psychomotor skills, graded using a checklist-based marking scheme ( Annex 3 ) developed by four content experts (Yip CC, Thng ZX, Hah YY, and Gan NY). Procedures The assessments were conducted at the Lee Kong Chian School of Medicine clinical examination suites, supervised by three invigilators (Ding J, Yap ASJ, and Ng SMS). MIQ-3 tests were administered in hardcopy immediately before intervention at Visit-1, and before PE assessments at Visits-4 and − 5. All subjects performed MIQ-3 visualization processes simultaneously under the verbal guidance of a tutor. All participants performed PE on healthy simulated patients without any abnormalities. CEX performances were recorded on an iPad (Apple Inc, Los Altos, California), with each participant reviewed and assessed retrospectively by two independent Ophthalmologists who were blinded to group assignments. Data Analysis Data analysis was performed using the IBM®SPSS® Statistics (version 25) software (International Business Machines Corporation, Armonk, New York, United States). Statistical significance was set at p < 0.05. Due to the small sample size (n < 30), Central Limit Theorem was referenced to justify non-parametric statistical tests usage, with data presented as median with inter-quartile range (Kwak & Kim, 2017 ). Results Recruitment Outcomes and Subject Demographics Of the 54 second year LKCSoM medical students who consented to participate, one student from the GPP group was excluded due to a videorecording error, resulting in a final sample size of 53. Psychomotor Assessment Inter-group (GMR versus GPP) and intra-group (Test-1 to Test-2) differences in CEX scores were computed (Table 1 ), using relevant statistical tests. Table 1 Data summary and statistical analysis table for CEX performance, presented in median with inter-quartile range with relevant statistical tests employed for inter and intra-group comparisons respectively. Visit-4/Test-1 Score Visit-5/Test-2 Score Wilcoxon Signed Rank Test GMR (n = 27) 35.000 [14.000] 40.000 [10.500] p = 0.015 GPP (n = 26) 33.250 [22.000] 36.250 [12.000] p = 0.353 Mann-Whitney U Test p = 0.908 p = 0.500 - Mann-Whitney U test demonstrated no statistically significant inter-group differences between Visit-4/Test-1 (GMR 35.000 [14.000] vs GPP 33.250 [22.000], p = 0.908) and Visit-5/Test-2 (GMR 40.000 [10.500] vs GPP 36.250 [12.000], p = 0.500). Wilcoxon Signed Rank test showed no significant intra-group differences between Tests-1 and − 2 for the GPP group (GPP 33.250 [22.000] vs 36.250 [12.000], p = 0.353). However, in the GMR group, Test-2 score was significantly higher than Test-1 (36.250 [12.000] vs 35.000 [14.000], p = 0.015). MI Ability Assessment The MI ability construct was presented as three separate components by the MIQ-3, namely Internal Visualization (IV), External Visualization (EV) and Kinaesthetic Visualization (KV). Intra-group comparisons were made across three assessment timeframes (Baseline, Visit-4, and Visit-5) using the Friedman’s Test (Table 2 ), followed by post-hoc Wilcoxon Signed Rank test with Bonferroni Adjustment (α = 0.017) on statistically significant findings (Table 3 ). Table 2 Data summary and statistical analysis table for MIQ-3 outcomes, presented in median with inter-quartile range, analysed using the Friedman’s test. Statistically significant differences are presented with an asterix (*). Baseline Visit-4 Visit-5 Friedman’s Test GMR (n = 27) IV 26.000 [6.000] 27.000 [5.000] 27.000 [5.000] 0.711 EV 24.000 [5.000] 25.000 [6.000] 26.000 [4.000] 0.036* KV 22.000 [8.000] 23.000 [7.000] 24.000 [6.000] 0.001* GPP (n = 26) IV 24.000 [4.500] 24.500 [6.000] 24.500 [4.500] 0.128 EV 24.000 [4.500] 23.500 [5.000] 24.500 [5.000] 0.202 KV 24.000 [6.000] 22.500 [8.000] 24.000 [6.250] 0.005* Table 3 Statistical analysis table for MIQ-3 outcome subgroup with statistically significant differences detected on the Friedman’s test with Bonferroni adjustment. Only p-values of post-hoc Wilcoxon Signed Rank test with Bonferroni Adjustment (α = 0.017) are presented. Post-hoc Wilcoxon Signed Rank Test p-value Baseline vs Visit-4 Visit-4 vs Visit-5 Baseline vs Visit-5 GMR EV 0.356 0.180 0.011 GMR KV 0.087 0.271 < 0.001 GPP KV 0.010 0.012 0.002 Internal Visualisation (IV) In terms of IV, there were no significant intra-group differences for both the GMR (26.000 [6.000] vs 27.000 [5.000] vs 27.000 [5.000], p = 0.711) and GPP (24.000 [4.500] vs 24.500 [6.000] vs 24.500 [4.500], p = 0.128) groups. External Visualisation (EV) In terms of EV, there were no significant intra-group differences for the GPP group (24.000 [4.500] vs 23.500 [5.000] vs 24.500 [5.000], p = 0.202). However, statistically significant intra-group differences were noted for the GMR group (24.000 [5.000] vs 25.000 [6.000] vs 26.000 [4.000], p = 0.036) group. Post-hoc analysis with Wilcoxon Signed Rank Test did not show significant differences between baseline and Visit-4 (24.000 [5.000] vs 25.000 [6.000], p = 0.356), nor between Visit-4 and Visit-5 (25.000 [6.000] vs 26.000 [4.000], p = 0.180). However, EV was significantly higher at Visit-5 compared to baseline (26.000 [4.000] vs 24.000 [5.000], p = 0.011). Kinaesthetic Visualisation (KV) In terms of KV, significant intra-group differences were noted for both the GPP (24.000 [6.000] vs 22.500 [8.000] vs 24.000 [6.250], p = 0.005) and GMR groups (22.000 [8.000] vs 23.000 [7.000] vs 24.000 [6.000], p = 0.001). For the GPP group, post-hoc analysis did not show significant differences between baseline and Visit-4 (24.000 [6.000] vs 22.500 [8.000], p = 0.087), nor between baseline and Visit-5 (24.000 [6.000] vs 24.000 [6.250], p = 0.271). However, KV was significantly higher at Visit-5 compared to Visit-4 (22.500 [8.000] vs 24.000 [6.250], p < 0.001). For the GMR group, post-hoc analysis showed significantly higher KV at Visit-4 compared to baseline (23.000 [7.000] vs 22.000 [8.000], p = 0.010), Visit-5 compared to Visit-4 (24.000 [6.000] vs 23.000 [7.000], p = 0.012), and Visit-5 compared to baseline (24.000 [6.000] vs 22.000 [8.000], p = 0.002). Correlation Analysis Correlation analysis was performed using the Spearman’s Rho (Table 4 ). Significant negative correlations were noted for the GMR group, between Visit-5/Test-2 score and baseline KV (Rho = -0.358, p = 0.048), as well as Visit-5/Test-2 score and Visit-4 KV (Rho = -0.417, p = 0.030). No other significant correlations were noted between CEX performance and MI ability. Table 4 Correlation analysis table for CEX test scores and MIQ-3 test outcomes. Data is presented as Spearman’s Rho with p-value in brackets, with significant correlations marked with an asterix (*). GMR Group (n = 27) GPP Group (n = 26) Visit-4/Test-1 Score Visit-5/Test-2 Score Visit-4/Test-1 Score Visit-5/Test-2 Score Baseline EV -0.006 (0.977) -0.173 (0.389) -0.71 (0.737) 0.116 (0.582) Visit-4 EV -0.260 (0.191) -0.104 (-0.605) -0.18 (0.929) 0.222 (0.277) Visit 5 EV -0.085 (0.672) -0.327 (0.096) 0.129 (0.530) 0.160 (0.435) Baseline IV 0.176 (0.381) -0.104 (0.605) -0.257 (0.214) 0.031 (0.883) Visit-4 IV 0.025 (0.900) -0.207 (0.300) -0.136 (0.506) 0.124 (0.547) Visit-5 IV 0.070 (0.730) -0.211 (0.292) -0.073 (0.725) 0.208 (0.307) Baseline KV -0.324 (0.099) -0.358 (0.048)* -0.327 (0.111) -0.254 (0.221) Visit-4 KV 0.025 (0.900) -0.417 (0.030)* 0.032 (0.877) 0.070 (0.733) Visit-5 KV -0.099 (0.624) -0.273 (0.168) 0.028 (0.893) 0.027 (0.897) Discussion In this study, we evaluated two key aspects of GMR compared to standard GPP. First, we assessed GMR's relative efficacy for acquiring and retaining PE skills amongst novices, by analysing students' psychomotor skill performance in the CEX format. Second, we examined GMR's impact on MR skills through students' MIQ-3 performance, which quantifies MI ability. Our results support the hypothesis that GMR is non-inferior to GPP and facilitates deliberate practice of CE skills. We also found evidence supporting our second hypothesis that MI is a trainable skill. For psychomotor skills, repeated GMR produced similar results to GPP, with no significant difference in CEX performance between the groups across visits. This aligns with the Theory of Motor Simulation, which suggests similar neuro-circuitry activation in both methods (Jeannerod, 2001 ). Our study also validated the findings of the IMAGINE study, showing similar results using a more robust control group. Additionally, we added value to existing literature by directly comparing GMR to GPP, whereas previous studies focused on MR as an adjunct to physical practice (Paige et al., 2015 ; Sanders et al., 2008 ). Despite the positive outcomes, it is crucial to note that GMR should not replace GPP, as effective development, consolidation, and storage of perceptual memory are foundational for MR (Martin et al., 1999 ). Despite no difference in Visit-5 CEX performance between groups, the GMR group showed consistent improvement in PE skills across visits. This stability in skill performance may be due to repetitive practice (Ericsson, 2004 ) during scheduled sessions. We suggest that the GMR group may have rehearsed PE mentally outside of practice sessions, as MR can be performed independently. These effects produced intra-group but not inter-group differences, possibly requiring a larger sample size or longer follow-up for clearer results. However, proving GMR's superiority over GPP may not be meaningful, as GPP remains the gold standard in clinical education. Importantly, GMR serves as a mimic and adjunct, not a replacement, for GPP in activating motor task neurocircuits (Jeannerod, 2001 ). Regarding MI ability, the improved EV and KV in the GMR group supports the existing literature suggesting that MR can be trained (Maillet et al., 2015 ). The lack of improvement in IV for both groups could be due to the small sample size and the relatively strong baseline IV (median score of 24 for both GMR and GPP groups). Interestingly, KV improved in the GPP group, possibly due to the learning effect from repeated MIQ-3 assessments, which may also explain the improvements in the GMR group. We also found a significant negative association between baseline and visit-4 KV with visit-5 CEX performance in the GMR group. However, the practical significance of this finding is uncertain, as no correlation was found for visit-5 KV or other MI components. Theoretically, better MI ability should correlate with greater gains from GMR practice. Notably, this study did not conduct a sample size calculation for MI ability evaluation, warranting further studies to assess changes in MI ability with repeated CE practice. Finally, we feel that motor actions in MIQ-3 may be more complex than the procedural steps of PE, and repeated practices with PE (GMR or GPP) may only be adequate to improve some but not all aspects of movement imagery. It may thus be interesting to repeat MIQ-3 assessments when studying the effects of GMR in other subspecialties such as Neurology (sensory, motor and reflex examinations). Medical education is costly locally and internationally, and research to reduce costs by comparing effective alternatives with existing teaching strategies will be beneficial (Frenk et al., 2022 ; Ng et al., 2009 ). This study supports the use of GMR as a viable teaching alternative to GPP. GMR could therefore potentially unlock significant cost-savings and minimise organisational difficulties without compromising on training effectiveness; the once off cost to prepare replay-able GMR materials would likely be minimal compared to the repeated costs and logistic difficulties of organising GPP sessions (i.e. coordinating the presence of expert tutors, simulated patients and learning spaces). GMR may even enhance learning outcomes. The asynchronous, location-independent nature of GMR can facilitate repeated CE practice, even without a practice partner, at students’ optimum learning time and pace. Replaying GMR materials would also provide more consistent instruction than variations between in-person tutorials. Additionally, the resultant improvements in MI ability may help learners to apply MR independently to other CE skills or clinical procedures. Nevertheless, a proper cost analysis study is required to comment on the true cost effectiveness of GMR as we did not consider the manpower costs for creating eLearning materials, student borne cost for acquiring eLearning devices, and the general costs for simulated patients/training venues as even the GMR group will require physical practice in reality (Walsh, 2016 ). Our study has two main strengths. First, we selected second-year medical students without prior eye-related knowledge, eliminating the confounding effect of pre-existing knowledge present in the IMAGINE study. Second, we used a strict grading system involving video recording and double expert review, reducing the stress of examiner presence and allowing repeated expert review to ensure accurate grading. Our study has several limitations, suggesting directions for future research. First, being purely quantitative, we could not confirm whether students engaged in MR as guided by the expert or merely listened and memorized the PE steps like a podcast. Future studies could use a mixed-methods approach to better understand the cognitive processes behind GMR and gain deeper insights into MI (Wasti et al., 2022 ). Secondly, we did not perform baseline pair matching based on academic performance from the previous years, and we cannot exclude its confounding effects. However, this may be slightly mitigated by the fact that all students are pre-clinical, without experience in both Ophthalmology as well as clinical examination under time constraints. Furthermore, the prior grades of these students would be solely based on Multiple Choice Question paper and not Objective Clinical Skills Examination; while this could serve as a surrogate, it may not be truly applicable for this type of practical/clinical skills research. Lastly, no sample size calculation was performed for the MI hypothesis, which may account for the lack of significant, consistent findings on MI improvement and its correlation with psychomotor skills. Future studies should conduct sample size calculations using our data for a more robust design. In summary, we have consistently shown GMR's effectiveness in supporting repetitive practice of CEs. However, despite its potential as a learning adjunct, GMR is not a "one size fits all" strategy, as its effectiveness may depend on an individual's MI ability. Further research is needed to better understand the complex interaction between GMR and MI ability and to uncover the underlying mechanisms. Abbreviations Clinical Examination (CE), Mental Rehearsal (MR), Guided Mental Rehearsal (GMR), Guided Physical Practice (GPP), mental imagery (MI), Mental Imagery Questionnaire-3 (MIQ-3), Lee Kong Chian School of Medicine (LKCSoM ), Clinical Evaluation eXercise (CEX) , Internal Visualization (IV), External Visualization (EV), Kinaesthetic Visualization (KV). Declarations Ethics approval and consent to participate: Ethics approval was obtained from the Nanyang Technological University Institutional Review Board. Written informed consent was obtained from participants above the legal age of 21, and parental consent was obtained for those below 21 years old. Consent for publication: The authors consent to publication with BMC Medical Education. Data Availability: Data is deposited as a password protected file in a secured computer. Available for review upon reasonable request. Competing Interests: The IMAGINE study group declares no conflicts of interest associated with this study. Funding: The IMAGINE study group would like to thank the National Healthcare Group for supporting this study with its HOMER Grant. Authors' contributions: Chee Chew Yip designed the study, created learning videos, delivered lectures, assessed student performance, and prepared the manuscript. Zheng Xian Thng, Yan Yee Hah, Nicola Yi'an Gan assessed student performance. Sean Ming Sheng Ng, Andrew Shi-jie Yap recruited subjects and facilitated study visits. Jianbin Ding designed the study, facilitated study visits, performed data analysis, and prepared the manuscript. All authors reviewed the manuscript Acknowledgements: Not applicable. References Ahmed, H., Allaf, M., & Elghazaly, H. (2020). COVID-19 and medical education. The Lancet Infectious Diseases , 20 (7), 777-778. https://doi.org/10.1016/S1473-3099(20)30226-7 Di Corrado, D., Guarnera, M., Guerrera, C. S., Maldonato, N. M., Di Nuovo, S., Castellano, S., & Coco, M. (2020). 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B., Akata, D., Ellmann, S., Huisman, M., Koff, D., Brinkmann, S., Bamberg, F., Zimmermann, O., Traikova, N. I., … Kloeckner, R. (2021). How covid-19 kick-started online learning in medical education—the DigiMed study. PLOS ONE , 16 (9). https://doi.org/10.1371/journal.pone.0257394 Walsh, K. (2016). Costs and assessment in medical education: a strategic view. Perspect Med Educ , 5 (5), 265-267. https://doi.org/10.1007/s40037-016-0299-8 Wasti, S. P., Simkhada, P., van Teijlingen, E. R., Sathian, B., & Banerjee, I. (2022). The Growing Importance of Mixed-Methods Research in Health. Nepal J Epidemiol , 12 (1), 1175-1178. https://doi.org/10.3126/nje.v12i1.43633 Wallace, L., Raison, N., Ghumman, F., Moran, A., Dasgupta, P., & Ahmed, K. (2017). Cognitive training: How can it be adapted for surgical education? Surgeon , 15 (4), 231-239. https://doi.org/10.1016/j.surge.2016.08.003 Williams, S. E., Cumming, J., Ntoumanis, N., Nordin-Bates, S. M., Ramsey, R., & Hall, C. (2012). Further validation and development of the movement imagery questionnaire. J Sport Exerc Psychol , 34 (5), 621-646. https://doi.org/10.1123/jsep.34.5.621 Additional Declarations No competing interests reported. Supplementary Files Appendices.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6314150","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":470560090,"identity":"68507844-152f-46c6-8747-42e9b60be0ba","order_by":0,"name":"CHEE CHEW YIP","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYDACZiBmbAASEkD8ASJmQLwWxhkQ1QS0MCBpYeYhRovBcd4DDD932Mjxz24+Jm27409iA3vzNgmGP7W4tRzmS2DsPZNmLHHnWJp07hmDxAaeY2USjG3H8WjhMWBmbDucuEEix+x2bhtQC5AhwdhwjJCW//UbJPK/3bYEaZF/YwZ0GEEtBxIMJHLYbjOCbeEBamGrwalFEuiXg71tyYYzbqSZ/+xtMzZu40krtkhsO4BTC9/5swcf/Gyzk+efkfzY4GebnGw/++GNNz78qcOpReEADwOqgWwgIoHhME4t8g082CVw2zIKRsEoGAUjDgAArEFTh6DiqrkAAAAASUVORK5CYII=","orcid":"","institution":"Lee Kong Chian School of Medicine, Nanyang Technological University","correspondingAuthor":true,"prefix":"","firstName":"CHEE","middleName":"CHEW","lastName":"YIP","suffix":""},{"id":470560092,"identity":"fe634e8c-33d3-49f5-8144-392f7498ceb3","order_by":1,"name":"ZHENG XIAN THNG","email":"","orcid":"","institution":"Lee Kong Chian School of Medicine, Nanyang Technological University","correspondingAuthor":false,"prefix":"","firstName":"ZHENG","middleName":"XIAN","lastName":"THNG","suffix":""},{"id":470560095,"identity":"f491418c-6697-4d4a-8339-b2fa6c5d2559","order_by":2,"name":"YAN YEE HAH","email":"","orcid":"","institution":"Lee Kong Chian School of Medicine, Nanyang Technological University","correspondingAuthor":false,"prefix":"","firstName":"YAN","middleName":"YEE","lastName":"HAH","suffix":""},{"id":470560097,"identity":"e1fe2f95-6849-4900-8a25-f21a96a41260","order_by":3,"name":"ANDREW SHI-JIE YAP","email":"","orcid":"","institution":"Lee Kong Chian School of Medicine, Nanyang Technological University","correspondingAuthor":false,"prefix":"","firstName":"ANDREW","middleName":"SHI-JIE","lastName":"YAP","suffix":""},{"id":470560098,"identity":"46766e89-daf6-43ad-a1c2-101b2c6cc6cf","order_by":4,"name":"SEAN MING SHENG NG","email":"","orcid":"","institution":"Lee Kong Chian School of Medicine, Nanyang Technological University","correspondingAuthor":false,"prefix":"","firstName":"SEAN","middleName":"MING SHENG","lastName":"NG","suffix":""},{"id":470560099,"identity":"9a8d779f-bebf-4b73-91b2-868d934665a9","order_by":5,"name":"NICOLA YI'AN GAN","email":"","orcid":"","institution":"Lee Kong Chian School of Medicine, Nanyang Technological University","correspondingAuthor":false,"prefix":"","firstName":"NICOLA","middleName":"YI'AN","lastName":"GAN","suffix":""},{"id":470560100,"identity":"2a39b788-562a-4e63-89bf-cbf04d90a56f","order_by":6,"name":"JIANBIN DING","email":"","orcid":"","institution":"Lee Kong Chian School of Medicine, Nanyang Technological University","correspondingAuthor":false,"prefix":"","firstName":"JIANBIN","middleName":"","lastName":"DING","suffix":""}],"badges":[],"createdAt":"2025-03-26 16:23:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6314150/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6314150/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84560801,"identity":"8728fa24-391c-4d0b-8417-3eda46acbbd8","added_by":"auto","created_at":"2025-06-13 13:04:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":114124,"visible":true,"origin":"","legend":"\u003cp\u003eprovides an overview of the intervention, instruments, and procedures of the GMR and GPP groups. All components were identical for both groups, except for the intervention where participants were randomly assigned to undergo either GMR or GPP.\u003c/p\u003e\n\u003cp\u003estudy flowchart.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6314150/v1/32ceacf00188c3d7025ca772.png"},{"id":95800811,"identity":"ece99d2f-69d8-4c09-b060-735e584d58ab","added_by":"auto","created_at":"2025-11-13 08:23:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":955171,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6314150/v1/f886cbab-de9b-4486-8486-c39351d905c8.pdf"},{"id":84560696,"identity":"cb343fca-7f63-4879-b847-4970d0a1a8ab","added_by":"auto","created_at":"2025-06-13 12:56:15","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":36276,"visible":true,"origin":"","legend":"","description":"","filename":"Appendices.docx","url":"https://assets-eu.researchsquare.com/files/rs-6314150/v1/9ff534f6871c7e0427575f43.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eInvestigating Mental Rehearsal's Applicability in Guiding Independent E-learning of Eye Examination Skills During the Pandemic – Part II (IMAGINE-II)\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eThe COVID-19 pandemic disrupted the traditional in-person teaching models for medical education (Ahmed et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) in favour of social-distancing compatible online-learning (Stoehr et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, the resultant lack of in-person repetitive practice and immediate feedback posed a major obstacle to the teaching and mastery of clinical examination (CE) skills, as outlined by the Deliberate Practice Theory (Ericsson, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2004\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne possible solution is the use of Mental Rehearsal (MR). MR involves retrieving perceptual information from memory to mentally visualize the steps of a motor task, allowing cognitive rehearsal without physical movement (Martin et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). MR technique is based on the Motor Simulation Theory, which suggests that MR activates similar neurocircuits as physical practice (Jeannerod, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). It is widely used in sports (Di Corrado et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Lin et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and surgical training (Souiki et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Williams et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). However, its applicability in undergraduate training is underexplored.\u003c/p\u003e \u003cp\u003eTo support novices lacking schematic knowledge and prior perceptual information, Guided Mental Rehearsal (GMR) was introduced, allowing experts to guide MR of psychomotor skills (Kosslyn et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Mahoney \u0026amp; Avener, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e1977\u003c/span\u003e). GMR is a cost-effective and convenient learning method, and may thus be worth promoting for teaching CE to undergraduates, especially in a pandemic context.\u003c/p\u003e \u003cp\u003eThe IMAGINE study demonstrated GMR's effectiveness in teaching medical students CE psychomotor skills in a single session (Ding et al, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This raises the question: can GMR serve as a reliable method for developing competency through repetitive practice? Further investigation is needed in two key areas to advance theory and practice.\u003c/p\u003e \u003cp\u003eFirstly, the IMAGINE study evaluated only a single GMR session and used peer-learning as the control group. Using Deliberate Practice Theory (Ericsson, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2004\u003c/span\u003e), we aim to investigate the potential of repeated GMR for skill mastery through repetitive practice. This longitudinal study assesses the effect of repeated GMR on skill acquisition and retention, reflecting real-life learning habits where learners engage in ongoing practice. We will also directly compare GMR with Guided Physical Practice (GPP), where learners perform CE on healthy simulated patients using GMR audio transcripts. Our primary hypothesis is that repeated GMR is non-inferior to repeated GPP for acquiring and retaining CE psychomotor skills, with the main outcome being CE performance during timed assessments.\u003c/p\u003e \u003cp\u003eSecondly, it is important to assess whether MI is a trainable skill. Learners have varying baseline mental imagery (MI) capabilities, influenced by factors such as age, gender, and background experiences (Floridou et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Those with lower MI ability may struggle to activate relevant neurocircuits (Jeannerod., 2001). However, evidence shows improved MI with repeated practice, even in patients with Parkinson's Disease (Maillet et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Thus, our secondary hypothesis is that MI, like CE, improves with repeated GMR practice. The outcome will be quantitatively assessed using MI-related indices from the validated Mental Imagery Questionnaire-3 (MIQ-3) (Williams et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting and Design\u003c/h2\u003e \u003cp\u003eThis study was conducted at the Lee Kong Chian School of Medicine (LKCSoM), Singapore, from October to November 2021. Ethics approval was obtained from the Nanyang Technological University Institutional Review Board. Written informed consent was obtained from participants above the legal age of 21, and parental consent was obtained for those below 21 years old.\u003c/p\u003e \u003cp\u003eThis longitudinal, randomized-controlled study compared the efficacy of repeated GMR (intervention) versus repeated GPP (control) in the E-learning of \u0026lsquo;Pupillary Examination\u0026rsquo; (PE).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSample Size Calculation\u003c/h3\u003e\n\u003cp\u003eSample size calculation was made by extrapolating the data obtained from the IMAGINE study (Ding et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Using the Cliff\u0026rsquo;s Delta method for non-parametric data, the effect size for IMAGINE study was 0.850. Thus, for the IMAGINE-II study, a sample size of 23 participants per group was required to achieve a desired power of 0.080 with an actual alpha of 0.050. In anticipation for possible participant withdrawal during the study, a decision was made to recruit 20% more than the calculated required sample size of 46.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eAll second-year, pre-clinical medical students from the LKCSoM Class of 2024 were recruited, and 54 consented to participate. Inclusion criteria was the successful completion of the first year of undergraduate, pre-clinical medical training. Exclusion criteria was the possession of clinical experience or pre-clinical knowledge regarding Ophthalmology. This exclusion was declaration based. None of the participants declared attending any formal eye related teachings prior to this study. Participants were randomly assigned to the control (GPP, n\u0026thinsp;=\u0026thinsp;27) or intervention (GMR, n\u0026thinsp;=\u0026thinsp;27) group.\u003c/p\u003e\n\u003ch3\u003eMaterials\u003c/h3\u003e\n\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eThis study had four main types of learning activities. All learning materials were developed iteratively by senior Ophthalmologists who had completed core faculty development courses in assessment and had at least five years of teaching experience.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eNeuro-Ophthalmology Tutorial\u003c/h2\u003e \u003cp\u003eThis was a 1-hour long face-to-face teaching on basic ocular anatomy and physiology related to PE. The purpose was to impart essential background knowledge to facilitate the subjects\u0026rsquo; understanding of PE subsequently.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSynchronous E-learning of Pupillary Examination via Google Drive (Alphabet Inc, Mountain View, California)\u003c/h3\u003e\n\u003cp\u003eStudents watched an eight-minute-long instructional video of an expert explaining and demonstrating the steps of PE.\u003c/p\u003e\n\u003ch3\u003eTutor-led Skill Demonstration with Physical Practice\u003c/h3\u003e\n\u003cp\u003eThis 30-minute interactive session included a tutor-led demonstration of PE, followed by student-led physical practice with ad-hoc Q\u0026amp;A. The aim was to consolidate newly acquired knowledge, as the participants lacked prior ophthalmic background and clinical experience.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eGMR versus GPP\u003c/h2\u003e \u003cp\u003eAsynchronous e-learning was continued for the GMR group (n\u0026thinsp;=\u0026thinsp;27). They listened to a six-minute audio recording of the content expert\u0026rsquo;s running commentary on PE of a normal patient. During the process, participants closed their eyes and attempted mental visualization of the steps described. This was repeated for 2 cycles over 15 minutes, inclusive of a 3-minute buffer time. The script for the running commentary is provided in \u003cem\u003eAnnex 1\u003c/em\u003e. The control group (n\u0026thinsp;=\u0026thinsp;26) underwent GPP of equivalent duration, allowing subjects to reference the printed transcript of the commentary (\u003cem\u003eAnnex 1\u003c/em\u003e) and go through the steps at their most comfortable pace. All participants were prohibited from revisiting the instructional video and practicing independently outside of scheduled sessions. This practice was repeated once at weeks 1 and 3, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eInstruments\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eMovement Imagery Questionnaire \u0026ndash; 3 (MIQ \u0026ndash; 3)\u003c/h2\u003e \u003cp\u003eThis validated 12-item Questionnaire utilizes a 7-point Likert scale to quantitatively assesses one\u0026rsquo;s ability to \u0026lsquo;see\u0026rsquo; (visual: first [internal] and third [external] person perspectives) and \u0026lsquo;feel\u0026rsquo; (kinaesthetic) the mentally visualized motor processes.(Williams et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) This provides a surrogate measure for an individual\u0026rsquo;s ability to generate and control vivid images. The MIQ-3 can be found in \u003cem\u003eAnnex 2\u003c/em\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eClinical Evaluation eXercise (CEX)\u003c/h2\u003e \u003cp\u003eThis six-minute timed assessment evaluated the participants\u0026rsquo; psychomotor skills, graded using a checklist-based marking scheme (\u003cem\u003eAnnex 3\u003c/em\u003e) developed by four content experts (Yip CC, Thng ZX, Hah YY, and Gan NY).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eProcedures\u003c/h2\u003e \u003cp\u003eThe assessments were conducted at the Lee Kong Chian School of Medicine clinical examination suites, supervised by three invigilators (Ding J, Yap ASJ, and Ng SMS).\u003c/p\u003e \u003cp\u003eMIQ-3 tests were administered in hardcopy immediately before intervention at Visit-1, and before PE assessments at Visits-4 and \u0026minus;\u0026thinsp;5. All subjects performed MIQ-3 visualization processes simultaneously under the verbal guidance of a tutor.\u003c/p\u003e \u003cp\u003eAll participants performed PE on healthy simulated patients without any abnormalities. CEX performances were recorded on an iPad (Apple Inc, Los Altos, California), with each participant reviewed and assessed retrospectively by two independent Ophthalmologists who were blinded to group assignments.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData analysis was performed using the IBM\u0026reg;SPSS\u0026reg; Statistics (version 25) software (International Business Machines Corporation, Armonk, New York, United States). Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Due to the small sample size (n\u0026thinsp;\u0026lt;\u0026thinsp;30), Central Limit Theorem was referenced to justify non-parametric statistical tests usage, with data presented as median with inter-quartile range (Kwak \u0026amp; Kim, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment Outcomes and Subject Demographics\u003c/h2\u003e \u003cp\u003eOf the 54 second year LKCSoM medical students who consented to participate, one student from the GPP group was excluded due to a videorecording error, resulting in a final sample size of 53.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePsychomotor Assessment\u003c/h2\u003e \u003cp\u003eInter-group (GMR versus GPP) and intra-group (Test-1 to Test-2) differences in CEX scores were computed (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), using relevant statistical tests.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eData summary and statistical analysis table for CEX performance, presented in median with inter-quartile range with relevant statistical tests employed for inter and intra-group comparisons respectively.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVisit-4/Test-1 Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVisit-5/Test-2 Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWilcoxon Signed Rank Test\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGMR\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.000 [14.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.000 [10.500]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGPP\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.250 [22.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.250 [12.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.353\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMann-Whitney U Test\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.908\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMann-Whitney U test demonstrated no statistically significant inter-group differences between Visit-4/Test-1 (GMR 35.000 [14.000] vs GPP 33.250 [22.000], p\u0026thinsp;=\u0026thinsp;0.908) and Visit-5/Test-2 (GMR 40.000 [10.500] vs GPP 36.250 [12.000], p\u0026thinsp;=\u0026thinsp;0.500).\u003c/p\u003e \u003cp\u003eWilcoxon Signed Rank test showed no significant intra-group differences between Tests-1 and \u0026minus;\u0026thinsp;2 for the GPP group (GPP 33.250 [22.000] vs 36.250 [12.000], p\u0026thinsp;=\u0026thinsp;0.353). However, in the GMR group, Test-2 score was significantly higher than Test-1 (36.250 [12.000] vs 35.000 [14.000], p\u0026thinsp;=\u0026thinsp;0.015).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eMI Ability Assessment\u003c/h2\u003e \u003cp\u003eThe MI ability construct was presented as three separate components by the MIQ-3, namely Internal Visualization (IV), External Visualization (EV) and Kinaesthetic Visualization (KV). Intra-group comparisons were made across three assessment timeframes (Baseline, Visit-4, and Visit-5) using the Friedman\u0026rsquo;s Test (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), followed by post-hoc Wilcoxon Signed Rank test with Bonferroni Adjustment (α\u0026thinsp;=\u0026thinsp;0.017) on statistically significant findings (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eData summary and statistical analysis table for MIQ-3 outcomes, presented in median with inter-quartile range, analysed using the Friedman\u0026rsquo;s test. Statistically significant differences are presented with an asterix (*).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVisit-4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVisit-5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFriedman\u0026rsquo;s Test\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eGMR\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.000 [6.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27.000 [5.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27.000 [5.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.711\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eEV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.000 [5.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.000 [6.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26.000 [4.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.036*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eKV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.000 [8.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.000 [7.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24.000 [6.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eGPP\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.000 [4.500]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.500 [6.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24.500 [4.500]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.128\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eEV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.000 [4.500]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.500 [5.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24.500 [5.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.202\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eKV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.000 [6.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.500 [8.000]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24.000 [6.250]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.005*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStatistical analysis table for MIQ-3 outcome subgroup with statistically significant differences detected on the Friedman\u0026rsquo;s test with Bonferroni adjustment. Only p-values of post-hoc Wilcoxon Signed Rank test with Bonferroni Adjustment (α\u0026thinsp;=\u0026thinsp;0.017) are presented.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003ePost-hoc Wilcoxon Signed Rank Test p-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline vs Visit-4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVisit-4 vs Visit-5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBaseline vs Visit-5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGMR EV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGMR KV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGPP KV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eInternal Visualisation (IV)\u003c/h2\u003e \u003cp\u003eIn terms of IV, there were no significant intra-group differences for both the GMR (26.000 [6.000] vs 27.000 [5.000] vs 27.000 [5.000], p\u0026thinsp;=\u0026thinsp;0.711) and GPP (24.000 [4.500] vs 24.500 [6.000] vs 24.500 [4.500], p\u0026thinsp;=\u0026thinsp;0.128) groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eExternal Visualisation (EV)\u003c/h2\u003e \u003cp\u003eIn terms of EV, there were no significant intra-group differences for the GPP group (24.000 [4.500] vs 23.500 [5.000] vs 24.500 [5.000], p\u0026thinsp;=\u0026thinsp;0.202).\u003c/p\u003e \u003cp\u003eHowever, statistically significant intra-group differences were noted for the GMR group (24.000 [5.000] vs 25.000 [6.000] vs 26.000 [4.000], p\u0026thinsp;=\u0026thinsp;0.036) group.\u003c/p\u003e \u003cp\u003ePost-hoc analysis with Wilcoxon Signed Rank Test did not show significant differences between baseline and Visit-4 (24.000 [5.000] vs 25.000 [6.000], p\u0026thinsp;=\u0026thinsp;0.356), nor between Visit-4 and Visit-5 (25.000 [6.000] vs 26.000 [4.000], p\u0026thinsp;=\u0026thinsp;0.180). However, EV was significantly higher at Visit-5 compared to baseline (26.000 [4.000] vs 24.000 [5.000], p\u0026thinsp;=\u0026thinsp;0.011).\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eKinaesthetic Visualisation (KV)\u003c/h2\u003e \u003cp\u003eIn terms of KV, significant intra-group differences were noted for both the GPP (24.000 [6.000] vs 22.500 [8.000] vs 24.000 [6.250], p\u0026thinsp;=\u0026thinsp;0.005) and GMR groups (22.000 [8.000] vs 23.000 [7.000] vs 24.000 [6.000], p\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eFor the GPP group, post-hoc analysis did not show significant differences between baseline and Visit-4 (24.000 [6.000] vs 22.500 [8.000], p\u0026thinsp;=\u0026thinsp;0.087), nor between baseline and Visit-5 (24.000 [6.000] vs 24.000 [6.250], p\u0026thinsp;=\u0026thinsp;0.271). However, KV was significantly higher at Visit-5 compared to Visit-4 (22.500 [8.000] vs 24.000 [6.250], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eFor the GMR group, post-hoc analysis showed significantly higher KV at Visit-4 compared to baseline (23.000 [7.000] vs 22.000 [8.000], p\u0026thinsp;=\u0026thinsp;0.010), Visit-5 compared to Visit-4 (24.000 [6.000] vs 23.000 [7.000], p\u0026thinsp;=\u0026thinsp;0.012), and Visit-5 compared to baseline (24.000 [6.000] vs 22.000 [8.000], p\u0026thinsp;=\u0026thinsp;0.002).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation Analysis\u003c/h2\u003e \u003cp\u003eCorrelation analysis was performed using the Spearman\u0026rsquo;s Rho (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSignificant negative correlations were noted for the GMR group, between Visit-5/Test-2 score and baseline KV (Rho = -0.358, p\u0026thinsp;=\u0026thinsp;0.048), as well as Visit-5/Test-2 score and Visit-4 KV (Rho = -0.417, p\u0026thinsp;=\u0026thinsp;0.030). No other significant correlations were noted between CEX performance and MI ability.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation analysis table for CEX test scores and MIQ-3 test outcomes. Data is presented as Spearman\u0026rsquo;s Rho with p-value in brackets, with significant correlations marked with an asterix (*).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGMR Group (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eGPP Group (n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eVisit-4/Test-1 Score\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eVisit-5/Test-2 Score\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eVisit-4/Test-1 Score\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eVisit-5/Test-2 Score\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBaseline EV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.006 (0.977)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.173 (0.389)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.71 (0.737)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.116 (0.582)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVisit-4 EV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.260 (0.191)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.104 (-0.605)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.18 (0.929)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.222 (0.277)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVisit 5 EV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.085 (0.672)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.327 (0.096)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.129 (0.530)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.160 (0.435)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBaseline IV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.176 (0.381)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.104 (0.605)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.257 (0.214)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.031 (0.883)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVisit-4 IV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.025 (0.900)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.207 (0.300)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.136 (0.506)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.124 (0.547)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVisit-5 IV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.070 (0.730)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.211 (0.292)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.073 (0.725)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.208 (0.307)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBaseline KV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.324 (0.099)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.358 (0.048)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.327 (0.111)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.254 (0.221)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVisit-4 KV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.025 (0.900)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.417 (0.030)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.032 (0.877)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.070 (0.733)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVisit-5 KV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.099 (0.624)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.273 (0.168)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.028 (0.893)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.027 (0.897)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we evaluated two key aspects of GMR compared to standard GPP. First, we assessed GMR's relative efficacy for acquiring and retaining PE skills amongst novices, by analysing students' psychomotor skill performance in the CEX format. Second, we examined GMR's impact on MR skills through students' MIQ-3 performance, which quantifies MI ability. Our results support the hypothesis that GMR is non-inferior to GPP and facilitates deliberate practice of CE skills. We also found evidence supporting our second hypothesis that MI is a trainable skill.\u003c/p\u003e \u003cp\u003eFor psychomotor skills, repeated GMR produced similar results to GPP, with no significant difference in CEX performance between the groups across visits. This aligns with the Theory of Motor Simulation, which suggests similar neuro-circuitry activation in both methods (Jeannerod, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). Our study also validated the findings of the IMAGINE study, showing similar results using a more robust control group. Additionally, we added value to existing literature by directly comparing GMR to GPP, whereas previous studies focused on MR as an adjunct to physical practice (Paige et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Sanders et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Despite the positive outcomes, it is crucial to note that GMR should not replace GPP, as effective development, consolidation, and storage of perceptual memory are foundational for MR (Martin et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e1999\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite no difference in Visit-5 CEX performance between groups, the GMR group showed consistent improvement in PE skills across visits. This stability in skill performance may be due to repetitive practice (Ericsson, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2004\u003c/span\u003e) during scheduled sessions. We suggest that the GMR group may have rehearsed PE mentally outside of practice sessions, as MR can be performed independently. These effects produced intra-group but not inter-group differences, possibly requiring a larger sample size or longer follow-up for clearer results. However, proving GMR's superiority over GPP may not be meaningful, as GPP remains the gold standard in clinical education. Importantly, GMR serves as a mimic and adjunct, not a replacement, for GPP in activating motor task neurocircuits (Jeannerod, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2001\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding MI ability, the improved EV and KV in the GMR group supports the existing literature suggesting that MR can be trained (Maillet et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The lack of improvement in IV for both groups could be due to the small sample size and the relatively strong baseline IV (median score of 24 for both GMR and GPP groups). Interestingly, KV improved in the GPP group, possibly due to the learning effect from repeated MIQ-3 assessments, which may also explain the improvements in the GMR group. We also found a significant negative association between baseline and visit-4 KV with visit-5 CEX performance in the GMR group. However, the practical significance of this finding is uncertain, as no correlation was found for visit-5 KV or other MI components. Theoretically, better MI ability should correlate with greater gains from GMR practice. Notably, this study did not conduct a sample size calculation for MI ability evaluation, warranting further studies to assess changes in MI ability with repeated CE practice. Finally, we feel that motor actions in MIQ-3 may be more complex than the procedural steps of PE, and repeated practices with PE (GMR or GPP) may only be adequate to improve some but not all aspects of movement imagery. It may thus be interesting to repeat MIQ-3 assessments when studying the effects of GMR in other subspecialties such as Neurology (sensory, motor and reflex examinations).\u003c/p\u003e \u003cp\u003eMedical education is costly locally and internationally, and research to reduce costs by comparing effective alternatives with existing teaching strategies will be beneficial (Frenk et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ng et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). This study supports the use of GMR as a viable teaching alternative to GPP. GMR could therefore potentially unlock significant cost-savings and minimise organisational difficulties without compromising on training effectiveness; the once off cost to prepare replay-able GMR materials would likely be minimal compared to the repeated costs and logistic difficulties of organising GPP sessions (i.e. coordinating the presence of expert tutors, simulated patients and learning spaces). GMR may even enhance learning outcomes. The asynchronous, location-independent nature of GMR can facilitate repeated CE practice, even without a practice partner, at students\u0026rsquo; optimum learning time and pace. Replaying GMR materials would also provide more consistent instruction than variations between in-person tutorials. Additionally, the resultant improvements in MI ability may help learners to apply MR independently to other CE skills or clinical procedures. Nevertheless, a proper cost analysis study is required to comment on the true cost effectiveness of GMR as we did not consider the manpower costs for creating eLearning materials, student borne cost for acquiring eLearning devices, and the general costs for simulated patients/training venues as even the GMR group will require physical practice in reality (Walsh, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur study has two main strengths. First, we selected second-year medical students without prior eye-related knowledge, eliminating the confounding effect of pre-existing knowledge present in the IMAGINE study. Second, we used a strict grading system involving video recording and double expert review, reducing the stress of examiner presence and allowing repeated expert review to ensure accurate grading.\u003c/p\u003e \u003cp\u003eOur study has several limitations, suggesting directions for future research. First, being purely quantitative, we could not confirm whether students engaged in MR as guided by the expert or merely listened and memorized the PE steps like a podcast. Future studies could use a mixed-methods approach to better understand the cognitive processes behind GMR and gain deeper insights into MI (Wasti et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Secondly, we did not perform baseline pair matching based on academic performance from the previous years, and we cannot exclude its confounding effects. However, this may be slightly mitigated by the fact that all students are pre-clinical, without experience in both Ophthalmology as well as clinical examination under time constraints. Furthermore, the prior grades of these students would be solely based on Multiple Choice Question paper and not Objective Clinical Skills Examination; while this could serve as a surrogate, it may not be truly applicable for this type of practical/clinical skills research. Lastly, no sample size calculation was performed for the MI hypothesis, which may account for the lack of significant, consistent findings on MI improvement and its correlation with psychomotor skills. Future studies should conduct sample size calculations using our data for a more robust design.\u003c/p\u003e \u003cp\u003eIn summary, we have consistently shown GMR's effectiveness in supporting repetitive practice of CEs. However, despite its potential as a learning adjunct, GMR is not a \"one size fits all\" strategy, as its effectiveness may depend on an individual's MI ability. Further research is needed to better understand the complex interaction between GMR and MI ability and to uncover the underlying mechanisms.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eClinical Examination (CE), Mental Rehearsal (MR), Guided Mental Rehearsal (GMR), Guided Physical Practice (GPP), mental imagery (MI), Mental Imagery Questionnaire-3 (MIQ-3), Lee Kong Chian School of Medicine (LKCSoM\u003cem\u003e),\u0026nbsp;\u003c/em\u003eClinical Evaluation eXercise (CEX)\u003cem\u003e,\u0026nbsp;\u003c/em\u003eInternal Visualization (IV), External Visualization (EV), Kinaesthetic Visualization (KV).\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate:\u0026nbsp;Ethics approval was obtained from the Nanyang Technological University Institutional Review Board. Written informed consent was obtained from participants above the legal age of 21, and parental consent was obtained for those below 21 years old.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication: The authors consent to publication with BMC Medical Education.\u003c/p\u003e\n\u003cp\u003eData Availability: Data is deposited as a password protected file in a secured computer. Available for review upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting Interests:\u0026nbsp;The IMAGINE study group declares no conflicts of interest associated with this study.\u003c/p\u003e\n\u003cp\u003eFunding:\u0026nbsp;The IMAGINE study group would like to thank the National Healthcare Group for supporting this study with its HOMER Grant.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions: Chee Chew Yip designed the study, created learning videos, delivered lectures, assessed student performance, and prepared the manuscript. Zheng Xian Thng, Yan Yee Hah, Nicola Yi\u0026apos;an Gan assessed student performance. Sean Ming Sheng Ng, Andrew Shi-jie Yap recruited subjects and facilitated study visits. Jianbin Ding designed the study, facilitated study visits, performed data analysis, and prepared the manuscript. All authors reviewed the manuscript\u003c/p\u003e\n\u003cp\u003eAcknowledgements: Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAhmed, H., Allaf, M., \u0026amp; Elghazaly, H. (2020). COVID-19 and medical education. \u003cem\u003eThe Lancet Infectious Diseases\u003c/em\u003e,\u003cem\u003e 20\u003c/em\u003e(7), 777-778. https://doi.org/10.1016/S1473-3099(20)30226-7 \u003c/li\u003e\n\u003cli\u003eDi Corrado, D., Guarnera, M., Guerrera, C. S., Maldonato, N. M., Di Nuovo, S., Castellano, S., \u0026amp; Coco, M. (2020). 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Central limit theorem: the cornerstone of modern statistics. \u003cem\u003eKorean J Anesthesiol\u003c/em\u003e,\u003cem\u003e 70\u003c/em\u003e(2), 144-156. https://doi.org/10.4097/kjae.2017.70.2.144 \u003c/li\u003e\n\u003cli\u003eLin, H. H., Lin, T. Y., Ling, Y., \u0026amp; Lo, C. C. (2021). Influence of Imagery Training on Adjusting the Pressure of Fin Swimmers, Improving Sports Performance and Stabilizing Psychological Quality. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e,\u003cem\u003e 18\u003c/em\u003e(22). https://doi.org/10.3390/ijerph182211767 \u003c/li\u003e\n\u003cli\u003eMahoney, M. J., \u0026amp; Avener, M. (1977). Psychology of the elite athlete: An exploratory study. \u003cem\u003eCognitive Therapy and Research\u003c/em\u003e,\u003cem\u003e 1\u003c/em\u003e(2), 135-141. https://doi.org/10.1007/BF01173634 \u003c/li\u003e\n\u003cli\u003eMaillet, A., Thobois, S., Fraix, V., Redout\u0026eacute;, J., Le Bars, D., Lavenne, F., Derost, P., Durif, F., Bloem, B. R., Krack, P., Pollak, P., \u0026amp; Deb\u0026ucirc;, B. (2015). Neural substrates of levodopa-responsive gait disorders and freezing in advanced Parkinson\u0026apos;s disease: a kineasthetic imagery approach. \u003cem\u003eHum Brain Mapp\u003c/em\u003e,\u003cem\u003e 36\u003c/em\u003e(3), 959-980. https://doi.org/10.1002/hbm.22679 \u003c/li\u003e\n\u003cli\u003eMartin, K. A., Moritz, S. E., \u0026amp; Hall, C. R. (1999). Imagery Use in Sport: A Literature Review and Applied Model. \u003cem\u003eThe Sport Psychologist\u003c/em\u003e,\u003cem\u003e 13\u003c/em\u003e(3), 245-268. https://doi.org/10.1123/tsp.13.3.245 \u003c/li\u003e\n\u003cli\u003eNg, C. L., Tambyah, P. A., \u0026amp; Wong, C. Y. (2009). Cost of medical education, financial assistance and medical school demographics in Singapore. \u003cem\u003eSingapore Med J\u003c/em\u003e,\u003cem\u003e 50\u003c/em\u003e(5), 462-467. \u003c/li\u003e\n\u003cli\u003ePaige, J. T., Yu, Q., Hunt, J. P., Marr, A. B., \u0026amp; Stuke, L. E. (2015). Thinking it through: mental rehearsal and performance on 2 types of laparoscopic cholecystectomy simulators. \u003cem\u003eJ Surg Educ\u003c/em\u003e,\u003cem\u003e 72\u003c/em\u003e(4), 740-748. https://doi.org/10.1016/j.jsurg.2015.01.012 \u003c/li\u003e\n\u003cli\u003eSanders, C. W., Sadoski, M., van Walsum, K., Bramson, R., Wiprud, R., \u0026amp; Fossum, T. W. (2008). Learning basic surgical skills with mental imagery: using the simulation centre in the mind. \u003cem\u003eMed Educ\u003c/em\u003e,\u003cem\u003e 42\u003c/em\u003e(6), 607-612. https://doi.org/10.1111/j.1365-2923.2007.02964.x \u003c/li\u003e\n\u003cli\u003eSouiki, T., Benzagmout, M., Alami, B., Ibn Majdoub, K., Toughrai, I., Mazaz, K., \u0026amp; Boujraf, S. (2021). Impact of mental imagery on enhancing surgical skills learning in novice\u0026apos;s surgeons: a pilot study. \u003cem\u003eBMC Med Educ\u003c/em\u003e,\u003cem\u003e 21\u003c/em\u003e(1), 545. https://doi.org/10.1186/s12909-021-02987-z \u003c/li\u003e\n\u003cli\u003eStoehr, F., M\u0026uuml;ller, L., Brady, A., Trilla, A., M\u0026auml;hringer-Kunz, A., Hahn, F., D\u0026uuml;ber, C., Becker, N., W\u0026ouml;rns, M.-A., Chapiro, J., Hinrichs, J. B., Akata, D., Ellmann, S., Huisman, M., Koff, D., Brinkmann, S., Bamberg, F., Zimmermann, O., Traikova, N. I., \u0026hellip; Kloeckner, R. (2021). How covid-19 kick-started online learning in medical education\u0026mdash;the DigiMed study. \u003cem\u003ePLOS ONE\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e(9). https://doi.org/10.1371/journal.pone.0257394\u003c/li\u003e\n\u003cli\u003eWalsh, K. (2016). Costs and assessment in medical education: a strategic view. \u003cem\u003ePerspect Med Educ\u003c/em\u003e,\u003cem\u003e 5\u003c/em\u003e(5), 265-267. https://doi.org/10.1007/s40037-016-0299-8 \u003c/li\u003e\n\u003cli\u003eWasti, S. P., Simkhada, P., van Teijlingen, E. R., Sathian, B., \u0026amp; Banerjee, I. (2022). The Growing Importance of Mixed-Methods Research in Health. \u003cem\u003eNepal J Epidemiol\u003c/em\u003e,\u003cem\u003e 12\u003c/em\u003e(1), 1175-1178. https://doi.org/10.3126/nje.v12i1.43633 \u003c/li\u003e\n\u003cli\u003eWallace, L., Raison, N., Ghumman, F., Moran, A., Dasgupta, P., \u0026amp; Ahmed, K. (2017). Cognitive training: How can it be adapted for surgical education? \u003cem\u003eSurgeon\u003c/em\u003e,\u003cem\u003e 15\u003c/em\u003e(4), 231-239. https://doi.org/10.1016/j.surge.2016.08.003 \u003c/li\u003e\n\u003cli\u003eWilliams, S. E., Cumming, J., Ntoumanis, N., Nordin-Bates, S. M., Ramsey, R., \u0026amp; Hall, C. (2012). Further validation and development of the movement imagery questionnaire. \u003cem\u003eJ Sport Exerc Psychol\u003c/em\u003e,\u003cem\u003e 34\u003c/em\u003e(5), 621-646. https://doi.org/10.1123/jsep.34.5.621 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mental Rehearsal, Clinical Examination, Deliberate Practice","lastPublishedDoi":"10.21203/rs.3.rs-6314150/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6314150/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eGuided Mental Rehearsal (GMR), underpinned by the Theory of Motor Simulation, supports the learning of psychomotor skills. We hypothesized that (a) GMR would be comparable to Guided Physical Practice (GPP) for learning Pupillary Examination (PE), and (b) Mental Imagery (MI) ability would improve with GMR practice.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis assessor-blinded, randomized controlled study included 53 pre-clinical students (GMR n\u0026thinsp;=\u0026thinsp;26, GPP n\u0026thinsp;=\u0026thinsp;27), with sample size calculated from pilot data (n\u0026thinsp;=\u0026thinsp;46, power\u0026thinsp;=\u0026thinsp;0.81, alpha\u0026thinsp;=\u0026thinsp;0.05). On day 1, baseline MI ability was assessed, followed by PE instruction. Practices (GMR or GPP) were conducted at weeks 1 and 3. PE performance and MI ability were reassessed using a checklist score sheet (month 1) and the Movement Imagery Questionnaire\u0026ndash;3 (month 2).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eData is presented as median with interquartile range. The Mann-Whitney U test showed no significant differences in PE performance between the GMR and GPP groups at months 1 (35.00 [14.00] vs. 33.25 [12.00], p\u0026thinsp;=\u0026thinsp;0.91) and 2 (40.00 [10.50] vs. 36.42 [12.00], p\u0026thinsp;=\u0026thinsp;0.50). In the GMR group, PE scores improved from month 1 to 2 (35.00 [14.00] vs. 40.00 [10.50], p\u0026thinsp;=\u0026thinsp;0.02, Wilcoxon Signed-Rank test). The Friedman test, followed by a post-hoc Wilcoxon Signed-Rank test with Bonferroni adjustment, indicated improved MI ability across baseline, 1 month, and 2 months (Kinaesthetic Visualization Score: 22.00 [8.00] vs. 23.00 [7.00] vs. 24.00 [6.00], p\u0026thinsp;\u0026lt;\u0026thinsp;0.01; External Visualization Score: 24.00 [5.00] vs. 25.00 [6.00] vs. 26.00 [4.00], p\u0026thinsp;=\u0026thinsp;0.36), which was not observed in the GPP group.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eRepeated GMR was found to be non-inferior to GPP for learning PE, and MI ability improved with deliberate GMR practice. GMR may serve as a cost-effective, resource-independent adjunct for acquiring clinical examination skills.\u003c/p\u003e","manuscriptTitle":"Investigating Mental Rehearsal's Applicability in Guiding Independent E-learning of Eye Examination Skills During the Pandemic – Part II (IMAGINE-II)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-13 12:56:10","doi":"10.21203/rs.3.rs-6314150/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bd0acf61-d7a2-4836-8320-2c4249375689","owner":[],"postedDate":"June 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-12T09:53:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-13 12:56:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6314150","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6314150","identity":"rs-6314150","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}