Understanding Basic Rehabilitation Techniques - Evaluation Report

Acknowledgments

The Understanding Basic Rehabilitation Techniques MOOC was developed and delivered by ReLAB-HS and Physiopedia. The United States Agency for International Development (USAID) funded Learning, Acting, and Building for Rehabilitation in Health Systems (ReLAB-HS) activity would like to thank the following people for their contributions to this work:

Course Coordinators: Rachael Lowe, Naomi O’Reilly

Content Contributors: Naomi O’Reilly, Vidya Acharya, Tarina van der Stockt, Wanda van Niekerk, Jess Bell, Matt Huey, Stacy Schiurring, Robin Tacchetti.

Webinar Content Experts: Stacy Schiurring, Matt Huey, Naomi O’Reilly

Course Facilitators: Naomi O’Reilly,  Jess Bell, Carin Hunter, Tarina van der Stockt, Lucy Aird.

Webinar Facilitators: Amanda Ager, Naomi O’Reilly, Lucy Aird.

This publication is made possible by the support of the American people through the United States Agency for International Development (USAID) through Learning, Acting, and Building for Rehabilitation in Health Systems (ReLAB-HS). The contents are the sole responsibility of Physiopedia and ReLAB-HS and do not necessarily reflect the views of USAID or the United States Government.

For information regarding this report, please contact: Rachael Lowe ([email protected])

Summary

From September 4 to October 1st, 2023, Learning, Acting, and Building for Rehabilitation in Health Systems (ReLAB-HS), led by Physiopedia, successfully delivered a Massive Open Online Course (MOOC) entitled “Understanding Basic Rehabilitation Techniques” via the Plus online learning platform. The program consisted of eight independent courses, which included:

1. Introduction to Rehabilitation Techniques and Intervention
2. Assessment Before Moving and Handling
3. Assessing Range of Motion
4. Assessing Muscle Strength
5. Assessing Muscle Length
6. Neurological Screen
7. Exploring Positioning
8. Exploring Transfers

In each course, the learner completed required learning activities and a final quiz that tested knowledge gained from the course. To complete the overall Understanding Rehabilitation as a Health Strategy program, the learner had the option to submit and pass a written assignment.

The program was also supported with two optional live webinars with physiotherapist, Stacy Schiurring and Matt Huey, to provide the opportunity for increased learner interaction and engagement with the content experts. The webinar recordings were also made available on the Plus platform for participants unable to access the webinars live.

1. Webinar 1: Clinical Case Studies of the Lower Limb
2. Webinar 2: Clinical Case Studies of the Upper Limb

Course Type: Free, Open, Online

Institution: ReLAB-HS via Physiopedia

About this Course: This MOOC aimed to equip health and social care professionals to develop knowledge of the fundamental rehabilitation techniques.

Target Audience: These courses were designed and written for health and social care professionals, clinicians, students, assistants, and other rehabilitation-related health systems stakeholders.

Time Commitment: 16 hours over four weeks (with an optional extra eight hours)

Date: September 4 to October 1, 2023, with live webinars on September 14 (Webinar 1: Clinical Case Studies of the Lower Limb)and on September 28 (Webinar 2: Clinical Case Studies of the Upper Limb ). These remain available on the Plus platform to members.

Requirements: Participants were required to complete online learning activities, engage with additional resources, and complete the course evaluations and quizzes.

Assessment: There was a quiz at the end of each course, and participants could complete an optional final written assignment to demonstrate knowledge gained from the programme of eight courses.

Awards: Eight course completion certificates awarding a total of 11.8 Plus (P+) points with an additional five Physioplus (P+) points available for the optional assignment to complete the programme.

Accreditation: Each individual course was accredited for continuing education and professional development (CE/CPD) in the USA, Australia and South African and is formally accepted without accreditation as a professional development activity by many other countries

Registrations MOOC: 11,331

Registrations Live Webinars: 533 Lower Limb Webinar and 526 Upper Limb Webinar

Countries Represented MOOC: 111

Countries Represented Live Webinars: 242 Lower Limb Webinar and 83 Upper Limb Webinar

Professions Represented MOOC: 32

Professions Represented Live Webinars: 20 Lower Limb Webinar and 8 Upper Limb Webinar

Introduction

The need for physical rehabilitation services is an urgent and growing global issue. According to a recent report, 2.41 billion individuals worldwide live with conditions that would benefit from rehabilitation services, with approximately 1 in 3 individuals requiring rehabilitation services throughout the course of their illness or injury. The proportion of the worldwide population over 60 will double in the next 30 years, the majority of whom will live with chronic diseases, particularly noncommunicable diseases. There are also approximately 150 million children and adolescents who experience disabilities, and injuries for people of all ages are becoming more frequent due to conflict, rapid urbanisation and motorisation. These changing health and demographic trends are contributing to rapid global increases in the numbers of people experiencing decline in functioning, resulting in enormous unmet rehabilitation needs. Much of these unmet needs are concentrated amongst the poorest and most vulnerable populations in low- and middle-income countries and conflict-affected settings, which are often ill equipped to cope with these increasing needs for rehabilitation services.

The World Health Organisation defines rehabilitation as "a set of measures that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning in interaction with their environments”. Rehabilitation is in effect composed of multiple components or interventions to address issues related to all domains within the World Health Organisation's  International Classification of Functioning, Disability and Health (ICF). These rehabilitation techniques and interventions address impairments, activity limitations and participation restrictions, considering contextual factors both personal and environmental, including assistive technology, that impact functioning. When selecting a rehabilitation intervention, it is always important to remember that one cannot change what you cannot measure. Hence, accurate measuring and monitoring using basic rehabilitation techniques, is essential to select and provide appropriate rehabilitation intervention. A clinician's care plan is only as thorough as their assessment. Confidence in fundamental rehabilitation assessment techniques is essential for efficient care.

During September 2023, ReLAB-HS, led by Physiopedia, delivered the Massive Open Online Course (MOOC), “Understanding Basic Rehabilitation Techniques Programme”. The MOOC was delivered as eight individual courses with an optional written final assignment to complete the full program of courses. The aim of the MOOC was to equip rehabilitation professionals with a comprehensive knowledge of fundamental rehabilitation techniques and principles guiding selection of rehabilitation techniques so they can play an effective and proactive role in global and local efforts to increase access to high quality rehabilitation and improve health outcomes.

The four-week-long program presented different topics exploring fundamental rehabilitation techniques through a variety of learning activities to suit all learning styles. The required learning activities within each course were developed to take between one to two hours depending on the participant's learning style, with optional activities provided should the participant wish to take part in additional learning. A short orientation period before the course provided participants with an opportunity to become familiar with the delivery platform and the topics via the provided pre-course resources.

The course was delivered through the Plus eLearning platform, an innovative platform specifically developed to provide online education and support participants with a personalized learning dashboard. For each course, the related learning activities were outlined on a specific course page. Participants engaged with each course and the respective learning activities, and their activity was recorded and displayed in their personal learning dashboard.

A course was considered complete once the learner finished all required learning activities and successfully passed the final quiz that tested the knowledge gained within each individual course of the program. On completion of each course the participants had the option to download a completion certificate and export a record of their learning from their activity log. There was also an optional written assignment designed for participants to apply the knowledge gained from the overall program consisting of  seven courses.

This report evaluates the engagement and experiences of the participants on the MOOC, Understanding Basic Rehabilitation Techniques Programme.

1.0 About the Program of Courses

1.1 Aim

Through this MOOC, ReLAB-HS aimed to equip health and social care professionals with a comprehensive knowledge of fundamental rehabilitation techniques and principles guiding selection of rehabilitation techniques so they can play an effective and proactive role in global and local efforts to increase access to high quality rehabilitation and improve health outcomes.

The program included an introduction to rehabilitation techniques and interventions, assessment before moving and handling and assessment for range of motion, muscle strength, muscle length and neurological screening and explored positioning and transfers.

1.2 Learning Objectives

At the end of this program of courses, participants were able to:

1. discuss the term "rehabilitation", the World Health Organization's definition of rehabilitation and the global need for rehabilitation
2. discuss the key elements of the International Classification of Functioning, Disability and Health (ICF) model and its role in rehabilitation
3. identify at least four principles that guide the selection of rehabilitation techniques and interventions
4. identify at least three factors that may impact patient safety during moving and handling tasks
5. discuss the measuring procedures and abnormal rates for at least two basic vital signs
6. select an appropriate response from healthcare professionals during moving and handling tasks based on given case scenarios
7. describe the key features of active, active-assisted, and passive range of motion and end-feel
8. identify at least three factors that can impact range of motion
9. describe at least three principles that guide the assessment and measurement of range of motion
10. identify at least two types of muscle contraction and at least three factors that can affect muscle strength
11. list at least two contraindications to muscle strength testing
12. discuss at least two methods of muscle strength testing, the Medical Research Council Scale for grading manual muscle testing and optimal positions for muscle strength testing
13. discuss the basic characteristics of skeletal muscle
14. describe the two main testing methods to assess muscle length, three measurement tools, at least two factors that affect muscle length and key principles of the muscle length assessment
15. identify an appropriate test or testing position to assess muscle length for at least three muscles
16. identify the purpose of the neurological screen and at least three indications to conduct a neurological screen
17. discuss the three main components of the neurological screen and the key features of upper and lower motor neurone lesions
18. identify the potential location of a lesion based on information from a neurological screen in a given case scenario
19. identify at least three indications and contraindications for therapeutic positioning
20. explain at least four key principles of patient positioning
21. identify at least five common patient positions used in rehabilitation and when they should be used
22. identify the key benefits, risks, indications, precautions and levels of assistance for patient transfers
23. discuss at least three guiding principles to ensure safe, appropriate transfers in clinical practice and common patient transfer techniques
24. identify an appropriate transfer technique for a patient in a simple case scenario

1.3 Intended Audience

This course is suitable for all rehabilitation professionals, students, and assistants, including but not limited to: physiotherapists, occupational therapists, speech and language therapists, rehabilitation doctors, rehabilitation nurses, prosthetists, orthotists, psychologists, audiologists, dietetics, social workers, and community-based health workers. Other health, social, and rehabilitation professionals interested in this subject are also invited to participate.

1.4 Cost to Participants

The course was free to all participants who completed the course within the 4-week timeframe and remains free to all Plus members and residents of low-income countries outside of this timeframe.

1.5 Course Availability

The program of eight courses were made available on September 4, 2023. Participants had until October 1, 2023 to complete the courses under their free access to Plus. The course remains available on the Plus platform to members; with membership free to individuals from low-income countries and available at a discounted rate to individuals in middle-income countries.

1.6 Courses, Course Awards, and Accreditation

Eight individual courses were created for the Understanding Basic Rehabilitation Techniques Program, which could each be completed individually or can be completed as a program of courses with an optional assignment. Plus provided individual course completion certificates to all participants that passed each individual course or attended the webinars. For each course completion participants were also awarded continuing professional development (CPD) points (equivalent to hours of learning). Individuals who completed all eight courses and completed the assignment were also provided with a program certificate in recognition of programme completion.

Course 1: Introduction to Rehabilitation Interventions (1.1 P+ Points)

Course 2: Assessment Before Moving and Handling (1.6 P+ Points)

Course 3: Assessing Range of Motion (1.7 P+ Points)

Course 4: Assessing Muscle Strength (1.8 P+ Points)

Course 5: Assessing Muscle Length (1.1 P+ Points)

Course 6: Neurological Screening (1.4 P+ Points)

Course 7: Exploring Positioning (1.8 P+ Points)

Course 8: Exploring Transfers (1.3 P+ Points)

Course Program: Understanding Basic Rehabilitation Techniques Programme P (5.0 P+ Points)

Webinar 1: Clinical Case Studies of the Lower Limb (1 P+ Points)

Webinar 2: Clinical Case Studies of the Upper Limb (1.2 P+ Points)

2.0 Demographics of the Participants

2.1 Country

Of the 11,331 individuals from 167 countries registered for the MOOC, 1388 individuals from 106 countries completed the Pre-Course Knowledge and Competency Self-Rating Tool. Course 1 (Introduction to Rehabilitation Interventions) was started by 1350 individuals from 103 countries, while 443 individuals from 67 countries started Course 8 (Exploring Transfers) before October 1, 2023. The Post-Course Knowledge and Competency Self-Rating Tool was completed by 102 individuals from 40 countries.

Figure 1 and Table 1 below show the numbers of participants and completion rates for the MOOC for the top 10 represented countries across all eight courses, with completion determined by completion of Course 8 of the MOOC. The highest level of participation for each of these countries occurred in Course 1 (Introduction to Rehabilitation Interventions) with 1350 total participation. Of the 10 most represented countries, South Africa had the highest completion rate overall at 44%, followed by Nigeria at 38%.

A full list of all countries with the number of participants from each country and completion rates for each course can be found in Appendix 1.  

Table 1: Top Ten Represented Countries Participation and Completion RatesData are the number of participants who started course 1 (n), the number of participants who completed course 8 (n1) and the percentage of country participants who completed course 8 (%).

Country	n (number started Course 1)	n1 (number completed Course 8)	% (percentage completed Course 8)
Egypt	136	47	35%
Nigeria	130	49	38%
United Kingdom	115	28	24%
India	66	22	33%
South Africa	52	23	44%
Australia	51	19	37%
Canada	47	16	34%
Pakistan	46	11	24%
United States	33	11	33%
Ukraine	29	7	24%

Table 2 - 4 below show a breakdown of participation data and completion rates based on country income classification. The highest number of participants for seven of the eight courses and the program were from low-middle-income countries. The highest participation numbers in an individual course was observed in Course 1 (Introduction to Rehabilitation Interventions) with 508 participants starting the course from low-middle income countries. This was closely followed by participants from high-income countries with 411 participants.

Table 2: Country Income Classification - Data are numbers (n) who started each course and number (n1) of participants from each country income classification who completed each course

Income Classification	Course 1 n (n1)	Course 2 n (n1)	Course 3 n (n1)	Course 4 n (n1)	Course 5 n (n1)	Course 6 n (n1)	Course 7 n (n1)	Course 8 n (n1)	Programme n (n1)
High	411 (259)	271 (207)	248 (193)	217 (173)	182 (154)	214 (143)	175 (134)	154 (128)	62 (1)
Upper-middle	121 (88)	87 (73)	79 (62)	65 (51)	58 (48)	62 (49)	52 (44)	50 (44)	19 (1)
Low-middle	508 (363)	346 (291)	278 (249)	225 (209)	200 (189)	203 (185)	177 (162)	177 (163)	112 (2)
Low	63 (50)	50 (45)	39 (41)	33 (33)	32 (32)	27 (27)	22 (22)	22 (22)	19 (0)

Table 3 shows the percentage completion data by country income classification for each individual course. While the lowest number of participants were seen from low-income countries, the completion rate for these participants was the highest across all groups. The highest completion rates for the individual courses were predominantly seen among those from low- (79% - 100%) and  low- to middle-income countries (71% - 95%) with 100% completion rates observed for low-income countries for Course 3 - 8., outlined in red below.

'Table 3: Country Income Classification Individual Course Completion Rate - Data are percentage (%) of participants from country income classification who completed each individual course.

Income Classification	Course 1 %	Course 2 %	Course 3 %	Course 4 %	Course 5 %	Course 6 %	Course 7 %	Course 8 %	Programme %
High	63%	76%	78%)	90%	85%	67%	77%	83%	2%
Upper-middle	73%	84%	78%	78%	83%	79%	85%	88%	5%
Low-middle	71%	84%	90%	93%	95%	91%	92%	92%	2%
Low	79%	90%	100%	100%	100%	100%	100%	100%	0%

Table.4 shows that overall MOOC completion rates, based on the percentage of participants who completed course 8 of the MOOC, were similar across all income classifications ranging from 31% for high-income countries to 36% for upper-middle income countries.

Income Classification	n (# started Course 1)	n1 (# completed Course 8)	n (% completed course 8)
High	411	128	31%
Upper-middle	121	44	36%
Low-middle	508	163	32%
Low	63	22	35%

Finally, Table.5 highlights the participation and completion rates of participants from ReLAB-HS countries, with the highest number of participants for all eight courses and the program coming from Pakistan, with participation ranges for each individual course ranging from 62 - 100%, with 100% completion seen by participants in Uganda in Course 7 and 8, outlined in red  below.

ReLAB-HS Country	Course 1 n (% )	Course 2 n (%)	Course 3 n (%)	Course 4 n (%)	Course 5 n (%)	Course 6 n (%)	Course 7 n (%)	Course 8 n (%)	Program n (%)
Pakistan	46 (70%)	28 (86%)	18 (89%)	20 (85%)	16 (94%)	16 (88%)	12 (92%)	12 (92%)	7 (14%)
Uganda	13 (62%)	11 (91%)	10 (90%)	8 (75%)	7 (86%)	7 (71%)	4 (100%)	4 (100%)	4 (0%)

While overall completion rates for each of the individual courses were high, the completion rates seen for the program of courses, which involved completion of an optional assignment, are much lower (0% - 5%). This is a pattern that has been shown across all MOOCs, suggesting minimal interest or motivation for participants to complete the optional assignment.

2.2 Professions

Thirty two different professions started the Understanding Basic Rehabilitation Techniques Programme before the end date of October 1, 2023. The top ten represented professions can be found in Table 6.

Physiotherapists and Physical Therapists including Doctors of Physical Therapy (DPT) represented the greatest number of participants across all eight courses, followed by students (all professions combined) and Occupational Therapists.

Completion rates varied significantly across all professions. A full list of participants' professional backgrounds can be found in Appendix 1.

Professional Background	Course 1 n (% )	Course 2 n (%)	Course 3 n (%)	Course 4 n (%)	Course 5 n (%)	Course 6 n (%)	Course 7 n (%)	Course 8 n (%)
Physiotherapist / Physical Therapist including DPT	722 (73%)	515 (84%)	439 (87%)	363 (88%)	311 (92%)	335 (83%)	280 (90%)	266 (93%)
Students (All Professions)	59 (68%)	38 (89%)	36 (83%)	31 (90%)	27 (85%)	29 (69%)	20 (85%)	19 (84%)
Occupational Therapist	26 (54%)	20 (65%)	16 (75%)	15 (73%)	13 (77%)	15 (67%)	13 (77%)	14 (64%)
Physiotherapy / Physical Therapy Assistant	16 (56%)	11 (73%)	11 (82%)	8 (100%)	9 (89%)	9 (89%)	8 (114%)	10 (80%)
Physical Rehabilitation Doctor	11 (45%)	5 (60%)	4 (100%)	4 (100%)	2 (100%)	3 (33%)	1 (100%)	2 (50%)
Massage Therapist	8 (50%)	4 (75%)	5   (40%)	3   (67%)	2   (100%)	2   (100%)	2   (100%)	3   (67%)
Chiropractor	5 (60%)	2   (100%)	2   (100%)	2   (100%)	2   (100%)	2   (100%)	2   (100%)	2   (100%)
Osteopath	4 (25%)	2 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)
Personal Trainer	5 (50%)	3 (33%)	1 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)
Educator	4 (50%)	3 (67%)	2 (50%)	1 (100%)	1 (100%)	2 (50%)	1 (100%)	1 (100%)

2.5 Gender and Age

Women were represented across all age ranges from 18-24 to 75+ and accounted for the greatest number of course participants in every age category, except for under 18, which only had one male participant. Course participants were represented across all age groups with the greatest number from those aged 25 - 34 years for both women and men. Table.8 highlights participation and completion rates for each individual course by gender.

ReLAB-HS Country	Course 1 n (% )	Course 2 n (%)	Course 3 n (%)	Course 4 n (%)	Course 5 n (%)	Course 6 n (%)	Course 7 n (%)	Course 8 n (%)
Female	566 (75%)	399 (86%)	342 (89%)	290 (89%)	256 (89%)	261 (82%)	225 (88%)	233 (88%)
Male	368 (72%)	254 (89%)	221 (90%)	173 (97%)	167 (96%)	160 (94%)	127 (100%)	138 (96%)
Other	1 (100%)	1 (100%)	1 (100%)	1 (100%)	1 (100%)	1 (100%)	1 (100%)	1 (100%)
Not Disclosed	158 (58%)	81 (63%)	69 (65%)	67 (61%)	45 (80%)	77 (53%)	46 (67%)	47 (60%)

2.5 Disability Related

Participants with a wide range of health impairments participated in the MOOC, with the majority of participants reporting no difficulty. For those who reported difficulty with doing certain activities as a result of a health impairment, difficulties with remembering or concentration was the highest reported, followed by vision, and then communication difficulties.

3.0 Engagement of the Participants

3.1 Platform

The Understanding Basic Rehabilitation Techniques programme and associated eight courses were delivered on the Plus learning platform. One hundred and two knowledge-sharing topic summary articles on Physiopedia were either created or updated for the learners to use throughout the duration of course.

These required articles received 170,692 total views before the final date of the MOOC on October 1, 2023. A list of knowledge-sharing topic summary articles on Physiopedia with total page views can be found in Appendix 2.  

Table 8: Top Ten Physiopedia Pages Reviewed

Professional Role	Number of Page Views
Dermatomes	38,403
Myotomes	36,281
Reflexes	20,019
Range of Motion Normative Values	16,939
Sensation	9,015
Assessing Range of Motion	6,471
Pulse Rate	5,675
Vital Signs	4,795
Assessing Muscle Strength	4,464
Blood Pressure	3,806

3.2 Required Learning Activities

The program included a total of 24 required learning activities and optional learning activities including watching videos, directed reading, practical workbooks and quizzes (full list of all required and optional learning activities can be found in Appendix 2).

To complete each course, participants were required to fully engage with all required learning activities and pass a quiz. Once successfully completed, Plus Points (equivalent to hours of learning) and a completion certificate were awarded. A breakdown of the number of required learning activities and the number of learning activities that were completed in each course can be found in Table 9.

Over the course of the MOOC 24,696 learning activities were logged with 13,962 Plus points awarded. The highest number of learning activities completed and Plus Points awarded within a single course occurred in Course 1, Introduction to Basic Rehabilitation Techniques, with 5844 learning activities logged during the MOOC, resulting in the award of 2,076 Plus Points.

Table 9: Learning activities logged and total Plus Points awarded for each course

	Course 1	Course 2	Course 3	Course 4	Course 5	Course 6	Course 7	Course 8
Required Learning Activities	3	3	3	3	3	3	3	3
Optional Learning Activities	1	1	3	3	3	3	1	3
Learning Activities Logged	5844	3433	3192	2646	2439	2256	1918	1871
Plus Points Awarded	2076	3911	1714	1583	1009	1005	852	1433

3.3 Discussion Forum and Case Studies

Each course contained a number of optional forum discussions. Learners were encouraged to engage with other international course participants on a wide range of different topics associated with the course through our Community of Practice platform, Rehabilitation Community.

This community culture has been developed to foster a professional community of learning among course participants. It is our shared set of beliefs, expectations and values that influence our individual learning and the ways in which the individuals in our community interact with one another and collaborate to achieve common objectives. These discussions were intended to provide a rich learning experience to the learner through self-reflection and community engagement. In total participants submitted 1664 posts over the course of the programme, an impressive level of engagement given all the Rehabilitation Community  discussions and case studies throughout this course were optional.

Table 10 presents an outline of the number of posts for each discussion and case study forum in each of the eight courses.

Table 10: Number of Forum Discussion Posts

	Course 1			Course 2	Course 3	Course 4	Course 5	Course 6	Course 7	Course 8
Discussion 1	251		Case Study 1	122	80	55	48	39	32	29
Discussion 2	219		Case Study 2	99	67	38	32	36	29	25
Discussion 3	191		Case Study 3	93	62	34	28	20	16	19

Data are Number (n) of Individual Posts

3.4 Webinars

Following the success of live webinars during the 2022 MOOC Understanding the Rehabilitation Needs of Displaced Person we incorporated two case study live webinars (Webinar 1, “Clinical Case Studies of the Lower Limb”, and Webinar 2, “Clinical Case Studies of the Upper Limb”) into the programme in week 2 and week 4 of the MOOC to provide additional opportunities for learner interaction and engagement to foster connections and minimize the impact of isolated learning. Further details on the webinars are available in the independently available webinar reports.

Table 9: Webinar Initiation and Completion

	Webinar 1 Overall Number (ReLAB-HS Numbers)	Webinar 2 Overall Number (ReLAB-HS Numbers)
Participants who Registered (n)	533	526
Participants who Attended (n)(n1)	242 (46)	270 (84)
Percentage who Attended (%) (%1)	45.4% (19%)	51% (31%)
Number Countries Attended (n)(n1)	52 (4)	84 (4)

Data are numbers (n) of participants from all countries, number (n1) of participants from ReLAB-HS countries, percentages (%) of participants who attended the webinar and percentage (%1) of participants from ReLAB-HS countries who attended the webinars.

Overall 91.3% of participants rated Webinar 1 Clinical Case Studies of the Lower Limb as great or excellent (41.8% great and 49.5% excellent), while 96% participants rated Webinar 2 on Clinical Case Studies of the Upper Limb as great or excellent (42.2% great and 53.8% excellent). With 96.7% of participants in Webinar 1 and 99.6% of participants in Webinar 2 reporting an increase in knowledge and / or skills related to the topic from participation in the webinar. The following testimonial from Webinar 1 Clinical Case Studies of the Lower Limb highlights both the quality of the instructors knowledge and the benefits of opportunities for live interaction with instructors to enhance learning.

“This webinar provided an invaluable opportunity to delve into real-world scenarios, offering a profound understanding of lower limb conditions and their treatment complexities. The knowledge and insights shared by the expert presenters were both enlightening and immediately applicable. What struck me most was the emphasis on evidence-based practice and the meticulous analysis of case studies. This has undoubtedly enhanced my clinical decision-making, enabling me to provide more precise and effective care to my patients with lower limb issues. Moreover, the webinar highlighted the significance of interdisciplinary collaboration and patient-centered care. It underscored the importance of working collaboratively with physical therapists and other healthcare professionals to deliver comprehensive and holistic treatments. I genuinely believe that the knowledge gained from this webinar will lead to improved patient outcomes and better overall care. It has rekindled my passion for continual learning and growth in the field of physical therapy. I am incredibly grateful for this enriching experience and look forward to implementing what I've learned into my practice. I wholeheartedly recommend this webinar to fellow healthcare professionals seeking to elevate their skills and provide exceptional care to their patients.”

3.5 Final Assignment

An optional final assignment was designed to give participants an opportunity to reflect on their learning and use the knowledge gained throughout the courses. Participants were asked to follow the assignment guidelines or video assignment guidelines on Physiopedia, and the Physiopedia team assessed the submitted assignments. To successfully pass the final assignment, learners needed to demonstrate evidence of learning from the course, academic skill with evidence-based writing, and correct referencing. Assignments had to be written in English.

Of the 18 assignments submitted before October 27, 2023, 6 met the assignment requirements and were rewarded with a passing grade and program certificate, with three needing minor amendments to achieve a passing grade.

3.6 Engagement versus Completion

Of the 11,331 learners who registered to take part in Understanding Basic Rehabilitation Techniques programme. 1,350 learners (12% of registered learners) began Course 1 (Introduction to Rehabilitation Interventions) of the Understanding Basic Rehabilitation Techniques programme before October 01, 2023, with 57% completion rate.

Course 5 (Assessing Muscle Length) and Course 7 (Exploring Positioning) had the highest completion rates with 81% of participants completing these two courses. Completion rates above 75% are seen for all courses of the programme, except for Course 1. The number of learners who began and completed each of the eight individual courses can be found in Table 8.

Table 8: Course Initiation and Completion

	Course 1	Course 2	Course 3	Course 4	Course 5	Course 6	Course 7	Course 8
Learners who Started	1350	823	716	610	524	508	443	466
Learners who Completed	764	619	548	468	425	406	358	366
Percentage Completion	57%	75%	77%	77%	81%	80%	81%	79%

Data are Numbers (n) of Learners

High numbers of dropouts are a common challenge for MOOC’s, suggested to be related to limited participant interactions (Fricton et al., 2015) and lack of face-to-face sessions, which generate a sense of isolation and disconnection (Jessica et al., 2021).

A total of 366 participants completed Course 8, the final mandatory course of the MOOC, which is a completion rate of 27%. While a reduction in number of participants was seen with each consecutive course in the Understanding Basic Rehabilitation Techniques programme, the completion rates for Course 2 - 8 were significantly greater than the initial course, suggesting a good connection with the content.

Overall, these completion rates are well above those seen for both health-related MOOC’s, with completion rates reported to range between 4.3% and 11% (Maxwell et al., 2018), and technology-related MOOC’s that are generally below 13% (Onah et al., 2014).

4.0 Participant Feedback

4.1 Quantitative Data

After the completion of each of the eight courses, learners had the option to share their feedback on the course. The learners were asked to rate their overall opinion of each course on a five-point likert scale ranging from excellent to poor. Overall, all eight courses received predominantly positive ratings. Figures 7 to 15 display the results for each course and the overall programme.

4.2 Qualitative Data

Participants were provided the opportunity to give qualitative feedback on their experience with each course. When asked, “What were the best elements of this course?” overall, the participants reported that they enjoyed the variety of learning resources and materials available throughout the courses. The case studies were also highlighted as a great mechanism for relating the content to specific clinical scenarios, which was supported by the two live webinars that further utilised case studies to highlight the integration of the content across all courses and the role each plays in assessment. Participants also reported that the videos were presented clearly and in an engaging way with excellent speakers who were passionate about the content.

In Course 1 (Introduction to Rehabilitation Techniques and Intervention) participants highlighted that the course provided an extensive review of fundamental rehabilitation techniques, and more importantly, it reinforced the role of the  ICF in my patient care practice.

“This first course was a marvelous conceptual overview of the necessary elements of rehabilitation, frameworks and the importance of outcome measures for practice. It succinctly and expressly impressed upon me core factors in a memorable manner that I know I will remember.”

Despite focusing on the basics it was considered a good introduction and refresher for those involved in either utilising,  explaining or teaching the holistic aspects of rehabilitation! This course's fundamentals of choosing rehabilitation interventions have been clearly depicted and beautifully woven together.

“Back to Basics is usually overlooked, but I think it has much to offer! I would recommend this course to every Rehabilitation Professional. It is easy to slip away from basics as you gain more years of experience. You tend to perform techniques you cannot explain, even though they are correct. It's a must-course for me.”

In Course 2 (Assessment Before Moving and Handling) participants highlighted that the course details how each assessment relates to rehabilitative intervention, delivered excellently with helpful examples, and was a great refresher as well as additional knowledge when it comes to handling patients that will benefit not only rehab professionals but also other rehabilitation staff, including nurses, physicians and support staff! The course also provided a great handy table that participants felt was something basic that can be shared with all primary caregivers.

“Vitals, bloodwork, and monitors are a staple to inpatient assessment and aim to assist in dealing with the patient's ongoing pathology. This course details how each assessment relates to rehabilitative intervention, delivered excellently with helpful examples.”

In Course 3 (Assessing Range of Motion) it was evident that participants knowledge of range of motion was enhanced significantly through the course and felt the course enhanced their current skills in performing range of motion assessments, and being better aware of the factors that can impact assessment.

“As a GP, I have performed ROM assessments for various patients. Yet, this course taught me I still have more to learn about this examination and that more information can be unearthed from examining ROM.”

“I did not know much about assessing the range of motion, but this course is excellent! It enhanced my knowledge regarding the assessment of range of motion. It covered all the essential components that every practitioner should know before assessing a patient's range of motion.”

In Course 4 (Assessing Muscle Strength) participants highlighted that the course was fantastic for both basic levels, but was also a great review for advanced level rehabilitation professionals. It not only provided a review of skeletal muscle physiology and biomechanics, but explored positions, techniques, and grading systems needed for muscle strength assessment.

“It is an excellent course for basic levels and fantastic revision for advanced levels!”

“This course supplied virtually every piece of information needed for muscle strength assessment in rehabilitation!”

In Course 5 (Assessing Muscle Length) it was evident that for many participants that it provided a refresher for concepts that significantly impact on muscle length assessment such as passive insufficiency and assessing muscle that cross two or more joints, that are frequently overlooked in rehabilitation.

“I did not know what passive insufficiency meant. Will definitely practice various muscle length assessments to become familiar with them. I shall be more mindful of testing positions while evaluating length of two joint or multi joint muscles.”

In Course 6 (Neurological Screen) reinforced the importance of using a neurological screen across a wide range of settings and not just for those who work within a neurology setting. Participants highlight that the course guides you through a step by step process for neurological screening with a fast, practical and organized approach so you don’t miss any hints that can help you with diagnostic impressions. Another key learning for many participants was the importance of consistency and documentation in screening such as use of the same dermatome maps.

“Serves as a review of fundamentals and stresses the importance of consistency. So I will definitely be paying attention to smaller details that can be overlooked when you are the only therapist in your practice.”

“I intend to use the same dermatomal map for tests and communicate appropriately to my colleagues to encourage better patient care and follow up.”

“I revised my knowledge of neurological screening and special tests to the same. I will have an increased awareness of subjective statements that will indicate the need for a neurological screening such as pins and needles, dizziness and decreased sensation. I will also look to employ the same dermatome map going forward as this will allow for consistency across treatments and for other clinicians to better use my note taking. I have revised the techniques used to test for the different senses such as pain, light touch and temperature, as well as how I test tendon reflexes and myotomes. This will give me more confidence as a first contact clinician going forward. I will also be able to better describe my tests to any patient that requires a screen, which will allow for decreased fear or worry and improve rapport during the session.”

In Course 7 (Exploring Positioning) and Course 8 (Exploring Transfers) participants felt this course was excellent for beginners but also provided superb revision with attention to details for people who are already practicing in a clinical setup. Participants most valued the practical strategies that can be utilised for use in patient positioning and handling. For many they found better use of terminology for describing positioning and transfers, which ensure improved documentation and handover of information to other rehabilitation professionals.

Finally, participants who completed the full programme of eight courses found the programme of courses to be a great refresher of the fundamental rehabilitation techniques that are used in daily clinical practice, helping to both verify current practice, leading to more confidence in application.

“Very good refreshment course going back to the basics to help with the assessment of the patients for better and effective rehabilitation outcome.”

“Even though I performed some of the assessments, going through these modules allowed me to reflect on my own practice and think about how I can improve my assessment to better form my rehabilitation plan.”

And most importantly, for many participants it has assisted them in being more intentional about their use of evidence based practice, and selection of techniques.

“I will be more intentional about implementing the techniques learned in assessment and interventions for my patients.”

When asked, “How could this course be improved?” participants again requested that the course be offered for a longer period of time, which has been a common theme seen year after year. While the MOOC itself ran for 4 weeks, the courses were still available for Plus members after the four week period, so the option was available by becoming a member of Plus. The case studies were popular and felt to have been a great addition to the course, but many requested access to more clinical case studies, and where possible video based case studies.

“I think the introduction of the two clinical case studies webinars have been a great addition. I would suggest more clinical case studies.”

“The significant factors were the practice videos and also the case studies that were used to illustrate and elaborate on the application of the courses to real life events.”

There were also many requests for further video demonstrations of the practical techniques across all areas of the programme, that can be used during the course but that would also be available as a clinical tool for use within clinical practice.

“More visual practical examples (demonstrations on patients) and less presentation.”

“Videos to explain the type of contractions and pictures for the MMT positions”

“More testing technique videos”

Overall from all the qualitative feedback and suggestions received from the participants, more access to practical demonstrations, case studies and live webinars are valued as key tools to enhance learning opportunities within the courses, and what participants would like to see more of.

“​​My objectives were fully met. The significant factors that led to this achievement were the introduction videos on every topic/course with the transcripts and easy to understand materials with links to more resources and further reading that really helped me gather so much more skills and knowledge. The videos for demonstrations that further increased my understanding. I also enjoyed the rehab community setting different group case study discussions that also helped a lot. The quizzes at the end of each course were also great to check my understanding. Furthermore the two Webinars on upper and lower limb case studies played a greater role to me.”

4.3 Impact on Knowledge

In order for a participant to show increased knowledge they needed to complete both the Pre- and Post-Course Knowledge and Competency Self-Rating Tools. Increase in knowledge can be evidenced by an increase in the average (mean) self-assessment scores between the Pre- and Post-Course Knowledge and Competency Self-Rating Tools as seen in Tables 9 and 10 below..

Only 102 participants completed the Post-Course Knowledge and Competency Self-Rating Tool, accounting for just 28% of the participants who completed the final course of the MOOC (Course 8 Exploring Transfers). Evidence from the Post-Course Knowledge and Competency Self-Rating Tool also shows improvement in knowledge across all areas following course completion.

Data was analyzed using the Mann U Whitney. All ten questions demonstrated statistically significant increases in scores indicating improvement in participant perceptions.

Table 10: Understanding Data from Pre- and Post-Competency Course Knowledge and Competency Self-Rating Tool - Constructs that Affect Patient Examination

Please rate your understanding of the following constructs that can affect the results of a patient examination on a 0-5 scale with 1 being no understanding and 5 being strong understanding.
Question	Pre Mean	Pos Mean	Mann U Whitney Pre Post
The influence of muscle strength on the ability of a patient to perform active range of motion (1)	4.09	4.50	<.001
The influence of muscle flexibility on the available range of motion of a joint (2)	3.79	4.45	<.001
The influence of muscle tone on the available range of motion of a joint (3)	3.77	4.42	<.001
The influence of the type of muscle contraction on the strength a patient is able to produce (4)	3.79	4.43	<.001
The influence of neuromuscular inhibition on the strength a patient is able to produce (5)	3.07	4.21	<.001

Table 9: Understanding Data from Pre- and Post-Competency Course Knowledge and Competency Self-Rating Tool - Type of Neurological Impairment

Please rate your understanding of the type of neurological impairment (peripheral nervous system or central nervous system) based on the results of the following neurological assessments on a 1-5 scale with 1 being no understanding and 5 being strong understanding.
Question	Mean Pre	Mean Post	Mann U Whitney Pre Post
Deep Tendon Reflexes e.g. achilles, patellar, biceps, triceps	3.43	4.36	<.001
Superficial / Cutaneous Reflexes e.g. plantar, anal	3.13	4.24	<.001
Pathological Reflexes e.g. Hofmann’s, Babinski, Clonus	3.23	4.23	<.001
Myotomes / Motor Assessment	3.34	4.35	<.001
Dermatomes / Sensory Assessment	3.49	4.38	<.001

Table 10: Understanding Data from Pre- and Post-Competency Course Knowledge and Competency Self-Rating Tool - Factors Affecting Patient Moving and Handling

Please rate your understanding of how the following factors can affect patient movement and handling on a 1-5 scale with 1 being no understanding and 5 being strong understanding.
Question	Mean Pre	Mean Post	Mann U Whitney Pre Post
Communication between Patient and Healthcare Professional	4.06	4.55	<.001
Patients Cardiorespiratory Status e.g. Heart Rate, Blood Pressure, Respiratory Status, Oxygen Saturation	3.76	4.38	<.001
Patients Neurological Status e.g. Tone, Sensation	3.70	4.41	<.001
Patients Orthopaedic Status e.g. Range of Motion, Strength, Weight-bearing Status	3.74	4.54	<.001
Lines and Leads e.g. Electrocardiogram (ECG), Arterial and Venous Lines, Urinary Catheters	3.11	3.86	<.001