The 2022 Massive Open Online Course (MOOC) to train physiotherapists in the management of people with spinal cord injuries: a qualitative and quantitative analysis of learners’ experiences and its impact

The paper addresses the need to upskill physiotherapy students and early-career physiotherapists in managing people with spinal cord injuries (SCI), noting limited exposure to SCI content in standard curricula and a resulting lack of confidence and expertise. Massive Open Online Courses (MOOCs) offer scalable, low-cost education, and the authors developed a 5-week SCI MOOC in collaboration with the International Spinal Cord Society (ISCoS), previously run in 2014, 2016, and 2018. The 2022 iteration expanded to five languages and attracted 2.5 times more participants than the 2018 offering. The study aims to evaluate learners’ experiences and the MOOC’s impact using the RE-AIM and Kirkpatrick frameworks, focusing on: (1) reach and engagement; (2) short-term changes in knowledge and confidence; (3) participant reactions; and (4) intended behavior changes in clinical practice and teaching.

The authors summarize contemporary MOOC scholarship, noting MOOCs’ growth as free, high-quality education platforms delivered via organizations such as edX, Coursera, Futurelearn, Udacity, and Khan Academy. Effective MOOCs often: provide multiple learning modalities; use real-world, authentic content; foster community and peer interaction; and include self-assessments and feedback. Critiques include poor suitability for hands-on clinical skills, low completion rates (as low as 4%), and debates about appropriate success metrics (completion vs. learner-defined goals and engagement). Prior evaluations of medical MOOCs emphasize community-building and adult learning principles. The authors situate their MOOC within this literature, acknowledging mixed evidence and suggesting evaluation via RE-AIM and Kirkpatrick is appropriate to capture multifaceted outcomes beyond completion rates.

Design: Observational evaluation using mixed qualitative and quantitative data sources aligned with RE-AIM and Kirkpatrick frameworks. Setting and timing: A 5-week MOOC (Nov 7–Dec 11, 2022) offered in English, Spanish, French, Portuguese, and Chinese. Participants: Intended for physiotherapy students and junior physiotherapists with limited SCI experience. Intervention (MOOC structure): Approximately 25 total hours (5 hours/week). Weekly activities included online lessons built around clinical scenarios (cases/videos), self-assessments/quizzes, engagement with additional resources, and participation in moderated discussion forums. Content included >1500 documents and ~150 videos, with access to a textbook underpinning the course. Participants could complete tasks asynchronously and received certificates upon attempting the final post-MOOC Knowledge Assessment. Social/community: Language-specific Facebook groups (English, French, Spanish, Portuguese) and a Weibo/alternative group for Chinese participants. Coordinators posted 2–3 weekly discussion threads tied to that week’s content; threads were moderated and closed weekly. Communication: Weekly instructions via email, website posts, and group posts; short weekly overview videos were produced in English and Portuguese. Assessments and data collection: - Knowledge Assessments: Pre- and post-MOOC multiple-choice assessments (20 questions). Pairs of matched-difficulty items were created; one item from each pair appeared pre-MOOC and the other post-MOOC to balance difficulty. The first-attempt post-MOOC score appeared on certificates. - Post-MOOC Evaluation: Likert-scale items (strongly disagree to strongly agree) plus open-ended questions on experience, perceived learning, and application. - Engagement metrics: Registration records (country, SCI experience level: student, ≤1 year, 2–5 years, >5 years); platform analytics (page views for SCIMOOC.org and elearnSCI.org; physiotherapyexercises.com), email delivery/opens, and social media metrics (members, active members, comments, reactions). - Text analysis: Searches of FB/Weibo threads and English Evaluation responses for terms indicating learning and confidence (e.g., “learned,” “did not know,” “understand,” “confidence”). Also counted positive sentiment terms and thematically summarized valued topics and learning features. Outcomes mapped to evaluation questions: - Reach: Registration demographics; website usage; membership and activity in social groups; email engagement; attrition trends across weeks. - Effectiveness: Median change in knowledge (pre/post); text evidence of increased knowledge/confidence. - Reaction: Quantitative ratings from Evaluation; qualitative sentiment and valued aspects/topics. - Behavior: Self-reported intentions to change clinical practice and teaching. Ethics: Approved by The University of Sydney Ethics Committee with waiver of consent per national guidelines.

- Reach: 25,737 registrants from 169 countries; largest cohorts from Egypt (28%), China (11%), India (10%), Australia (5%), Brazil (4%), UK (4%), Saudi Arabia (3%), Nigeria (2%), Pakistan (2%), France (2%). - Engagement: 16,298 participants joined FB/Weibo groups; 13,725 FB users classified as active members; ~20,000 comments and ~22,000 reactions posted. English FB discussion comments declined from ~1400 in week 1 to ~65 in week 5 (200–700 posts/day). Emails sent ranged from ~14,000 pre-course to 25,271 in week 5; open rates fell to ~40% by week 5. - Website analytics: SCIMOOC.org median 10,712 page views/day (IQR 6872–14,050). elearnSCI.org median 23,150 page views/day during the MOOC (IQR 18,091–29,325), a ~35-fold increase vs. pre-MOOC (median 549/day, IQR 464–911); 7% decrease in page views from week 1 to week 5. Physiotherapyexercises.com increased from ~10,000/day pre-MOOC to ~16,000/day during weeks 4–5. - Attrition: Indicators varied (7%–81% attrition depending on metric). Using elearnSCI.org usage as a robust proxy, authors estimate ~25% of starters worked through most of the content (~6,250 learners). - Effectiveness (knowledge/confidence): Among 4016 participants who completed both assessments, median knowledge gain was 25% (IQR 10–45%). Text analyses indicated frequent mentions of having learned new material and increased confidence. - Reaction (satisfaction): In the post-MOOC Evaluation, 98% rated the MOOC as good/very good. Positive sentiment terms such as “amazing/awesome/brilliant/fantastic/great/superb/wonderful” appeared hundreds of times; “learned a lot” and similar phrases were common. - Valued topics/features: Frequently cited topics included physiotherapyexercises.com, assessment tools, wheelchair skills, motor and strength training, neurological classification of SCI, autonomic dysreflexia, and upper limb function. Valued learning features included the diversity of videos (476 mentions), case studies (156), use of physiotherapyexercises.com (174), availability of the course book (392), self-assessments/quizzes (108), overall structure/format (709), and international peer engagement (138). - Behavior (intentions): Many participants reported intentions to change clinical practice (e.g., task breakdown, feedback, motor skill training, transfer training) and to use course resources in teaching and patient care.

The MOOC reached a large, global audience—including regions with limited SCI training opportunities—demonstrating the scalability and feasibility of delivering SCI physiotherapy education online. The estimated engagement suggests a substantial subset completed most content despite typical MOOC attrition patterns. Knowledge gains and overwhelmingly positive reactions indicate the course was effective in enhancing immediate knowledge and confidence. Participants valued the practical, video-rich, case-based approach, and access to tools (e.g., physiotherapyexercises.com) and a course textbook. The FB discussion forums and additional readings were less favorably received, highlighting areas for design improvement to foster small-group interaction and clearer expectations. While many participants expressed intentions to change practice and teaching, objectively measuring real-world behavior change remains challenging. The findings support MOOCs as resource-efficient strategies for professional development in SCI physiotherapy, with implications for expanding similar initiatives to other topics and professions. Future work should strengthen evaluation rigor (reduce selection bias in surveys, capture broader outcomes) and explore methods to assess sustained practice change.

The 2022 multilingual SCI MOOC effectively increased physiotherapists’ knowledge and confidence, was highly rated by participants, and stimulated intentions to improve clinical practice and teaching related to SCI management. The program demonstrated substantial global reach and engagement, providing cost-effective, scalable training not feasible through traditional workshops. Future efforts should refine community engagement (e.g., improved discussion formats), broaden accessibility, and develop robust methods to evaluate long-term behavior change and patient impact. Similar MOOCs could be developed for other professional groups and SCI-related topics to further upskill the global workforce.

- Selection and response bias: Only a subset completed pre/post assessments and the post-MOOC Evaluation; those most satisfied or engaged may be overrepresented. - Measurement limitations: Knowledge assessments emphasized clinical content but may not fully represent competencies; matching of pre/post items mitigated but does not eliminate testing limitations. - Attrition and engagement metrics: Completion/engagement indicators varied widely and may not capture partial but meaningful participation. - Behavior change not directly measured: Intentions to change practice were reported, but actual clinical behavior changes and patient outcomes were not objectively tracked. - Platform and access issues: Some participants reported technical barriers, video access problems, and less favorable views of FB discussions/additional readings, possibly affecting engagement. - Generalizability: Findings pertain to a specific MOOC structure and topic; results may not generalize to all MOOCs or clinical skills training contexts.