Introduction

A well-educated global workforce can potentially improve the lives of people with spinal cord injury (SCI).1 Physiotherapists are part of this workforce. It is therefore important to find effective and inexpensive ways to educate physiotherapists about SCI. This has traditionally been carried out through face-to-face undergraduate and graduate physiotherapy educational programs at colleges and universities around the world. However, this method of education is problematic because SCI is highly specialised and it is difficult for educational institutes to find appropriately qualified academics to teach this part of the physiotherapy curriculum. This is particularly a problem for small academic institutes and for countries in which physiotherapy is a young profession. Physiotherapists also receive education in SCI through courses and workshops; however, these are often run on a commercial basis and consequently can be cost prohibitive. In some countries, there are few senior SCI physiotherapists with experience in education who can run courses and worskhops. This adds another challenge.

The International Spinal Cord Society has attempted to address the need for education in SCI by developing www.elearnSCI.org, a free resource that contains seven online learning modules.2 One of these seven modules is specifically for physiotherapy students and physiotherapists. It contains 14 lessons covering a range of physiotherapy core topics. Each lesson contains a short didactic overview of the topic, interactive activities and a self-assessment quiz. Dispersed throughout the physiotherapy module are over 150 videos of people with SCI, and interviews with both physiotherapists and patients from a diverse range of countries. The interactive activities are where most of the learning content is presented.

The physiotherapy module of www.elearnSCI.org aims to provide a consistent learning experience in SCI for physiotherapy students and physiotherapists. However, users need to work through the lessons on their own. This requires self-discipline and motivation. It was hypothesised that a Massive Open Online Course (MOOC) based around the physiotherapy-specific modules might help users maintain interest and motivation to complete the lessons and in this way learn about SCI. The MOOC would also provide the opportunity to include additional activities, which could extend more capable users and help reinforce some key points for others.

MOOCs have existed for approximately 10 years, although the term ‘MOOC’ was only coined in 2008.3, 4, 5, 6 MOOCs are ‘massive’ because they sometimes have 1000s of students, they are ‘open’ because they are free, they are ‘online’ because the course is delivered by the web and they are ‘courses’ because they have a curriculum and learning objectives.7 MOOCs have various formats but most involve listening to lectures online, completing tasks, reading articles and completing self-assessments. Importantly, most have online forums that provide participants with the opportunity to engage with fellow students and teachers from around the world. These later aspects of MOOCs are considered particularly important because they develop an online virtual classroom often fostering a sense of collectiveness that helps maintain motivation to learn.3,8 MOOCs are increasingly popular because they are inexpensive to run and provide students from all countries access to the same level of education.3,5, 6, 7, 8, 9, 10, 11 Therefore, Physiopedia in collaboration with the International Spinal Cord Society partnered to run a MOOC for physiotherapy students and physiotherapists. This paper describes the outcome of this MOOC. In particular, it focuses on user participation and satisfaction, and changes in knowledge.

Methods

Design

This is a descriptive audit of a 5-week MOOC that was run for physiotherapy students and physiotherapists between 28 April and 30 May 2014. The MOOC was managed by Physiopedia and run in collaboration with the International Spinal Cord Society. The MOOC was accredited by the World Confederation for Physical Therapy, and those who successfully completed it were provided with a certificate of completion and 15 International Physical Therapy Continuing Education Units.

Details about the MOOC

Details about the MOOC can be found at http://www.physio-pedia.com/Physiotherapy_Management_of_Spinal_Cord_Injuries. The MOOC primarily targeted physiotherapy students and junior physiotherapists with little prior experience in SCI but with a general understanding of the principles of physiotherapy. It was advertised widely through newsletters associated with the World Confederation for Physical Therapy, the International Network of Spinal Cord Injury Physiotherapists (www.scipt.org), Physiopedia and ISCoS, and through social media associated with the International Network of Spinal Cord Injury Physiotherapists and physiopedia. The aim of the MOOC was to equip participants with sufficient knowledge to manage a person with SCI. This included assessing impairments, activity limitations and participation restrictions, setting appropriate goals of treatment, formulating an evidence-based treatment plan, implementing treatment and evaluating its success. The MOOC was free and required participants to register and then devote 3 h per week for 5 weeks (total of 15 h). There were two designated teachers of the MOOC. Both had clinical and academic experience in the physiotherapy management of SCI.

Participants were given three tasks each week, namely:

  1. 1

    Complete 2 to 3 of the physiotherapy-specific lessons that are part of www.elearnSCI.org.

  2. 2

    Look at additional readings, videos and resources. This included selected readings from the course text book,12 which was made freely available for participants to read online for the duration of the course.

  3. 3

    Contribute to an online discussion run through a closed Facebook group.

Participants were sent an email at the beginning of each week. This directed them to an appropriate URL to find the details of what they were expected to do for that week. The weekly emails also provided an opportunity to communicate any issues that had arisen in the previous week. In addition, one of the course coordinators was videoed each week in an informal way to introduce the content of each week. This was posted on YouTube.

The Facebook group was an important aspect of the MOOC and participants were encouraged to join and contribute to the discussions. Two to four discussion topics were posted each week to facilitate discussion (see Table 1 for examples of discussion topics). Some of the discussion topics were intentionally designed to be slightly controversial and to encourage participants to think, read more about the evidence or to seek information from other sources. Some discussion topics invited participants to reflect on what they had learnt during the week or to reflect on aspects of the learning experience they had enjoyed. Only participants of the course were invited to join the Facebook group and post messages, although this was difficult to monitor, and at least some who joined the Facebook group were not registered on the course.

Table 1 Four examples of discussion topics that were posted to the Facebook group with the number of posts to each
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Participants of the MOOC were given many opportunities at different stages to assess their knowledge and understanding through multiple self-assessments and different interactive activities, which formed part of the physiotherapy lessons accessed through www.elearnSCI.org. For example, there were 10 multiple choice questions at the end of each lesson in www.elearnSCI.org.

Assessment of participation and satisfaction

Participation and satisfaction with the MOOC were gauged through the pre- and post-MOOC knowledge assessment, an online course evaluation, Facebook activity and internet-based usage statistics.

Pre-MOOC and post-MOOC knowledge assessments

Participants’ knowledge was assessed at the beginning and end of the MOOC through 20 multiple choice questions. The questions in the two knowledge assessments were slightly different and designed specifically for the MOOC. Initially, 20 pairs of questions were composed, which were similar in content and complexity. One question of each pair was randomly allocated to the pre-MOOC knowledge assessment and the other to the post-MOOC knowledge assessment.

Course evaluation by participants

This was administered online at the completion of the course. It consisted of 13 positive statements designed to determine satisfaction with the learning experience (see Figure 1 for the statements). Participants were required to respond to each statement on a 5-point scale. In addition, there were two open-ended questions, which required participants to identify aspects of the MOOC that worked well and aspects of the MOOC that did not work well.

Figure 1
figure 1figure 1

Responses to the 13 statements comprising the course evaluation. The responses are expressed as percentage. The total number of respondents was 1029.

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Facebook activity

The number of people who joined the Facebook group and the number of posts to each discussion topic were recorded to indicate course engagement and participation.

Online website tracking systems

Google analytics and an inbuilt tracking system were used to determine how many participants completed the multiple-choice questions at the end of each lesson in www.elearnSCI.org, how many participants opened their emails each week (these contained directions to the URL providing detailed instructions for the week) and how many participants accessed the URL with the instructions for each week.

Results

The number of registrants for the course was 3523. Registrants were from 108 countries (see Table 2) and had a mix of experience (see Table 3). The most represented countries were United States of America (718), Australia (482), UK (383), India (185), Canada (172), Thailand (137) and Pakistan (118).

Table 2 The number of course participants from different countries (missing data on two participants)
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Table 3 The number of participants who were students, physiotherapists with no experience in SCI, physiotherapists with <1 year experience in SCI, physiotherapists with 2–5 years experience in SCI and physiotherapists with >5 years experience in SCI (missing data on one participant)
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Knowledge assessments

The pre- and post-MOOC knowledge assessments were attempted by 2187 and 1506 participants, respectively (see Figure 2a for results). However, some participants completed just the pre- or post-MOOC knowledge assessments. One thousand one hundred and twenty-one students did both assessments (see Figure 2b for results). The median (interquartile range) result of those who did both assessments were 70% (60–80%) and 90% (80–95%), respectively.

Figure 2
figure 2

Scores for the pre- and post-MOOC knowledge assessments (median, interquartile range). (a) Includes all participants who completed the assessments and reflects the results of participants’ best attempt (some participants made repeated attempts). (b) Includes only the participants who completed both the pre- and post-MOOC assessments and reflects the results of participants’ first attempt.

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Course evaluation by participants

The course evaluation was completed by 1029 participants. More than 80% of respondents agreed or strongly agreed with 12 of the 13 positive statements about the learning experience posed to them as part of the course evaluation (see Figure 1). The exception was one statement about the usefulness of the Facebook discussion in which 65% ‘agreed’ or ‘strongly agreed’, and 23% were ‘neutral’ (the remaining 8% either ‘disagreed’ or ‘strongly disagreed’). The two open-ended questions were answered extensively in over 39 500 words. The responses were counted by general themes (see Tables 4 and 5). The two most commonly cited positive aspects of the MOOC were: (1) the opportunity to engage with other physiotherapy students and physiotherapists around the world, and (2) the number of images and interactive screens on the www.elearnSCI.org lessons. The two most commonly cited negative aspects of the MOOC were: (1) the time it took each week to complete all the tasks (it took some participants longer than the allocated 3 h), and (2) the excessive number of posts on the Facebook discussion threads.

Table 4 The 10 most common responses to the open-ended questions on the course evaluation, which asked participants to nominate the aspects of the MOOC that worked well
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Table 5 The 10 most common responses to the open-ended questions on the course evaluation, which asked participants to nominate the aspects of the MOOC that did not work well
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Facebook activity

Engagement with the Facebook discussion was good with 2529 people joining the Facebook group and together contributing to over 10 000 posts over the 5-week period. Each discussion topic attracted between 393 posts (week 5—discussion topic no. 2—staying fit and healthy) to 829 posts (week 1—discussion topic no. 2—classification of SCI) with an obvious fall off in engagement over the duration of the course. One discussion topic during week 4 required students to use www.physiotherapyexercises.com to design an appropriate exercise program for a patient and then post the URL of the exercise program to the Facebook group. This was quite a complex task but attracted 506 posts.

Online website tracking systems

The multiple-choice questions at the end of each lesson in the physiotherapy-specific module of www.elearnSCI.org were completed by between 1000 and 1500 people (the number varied for each lesson). Initially, 80% of students opened their emails which contained directions to the URL providing detailed instructions for the week. This dropped to 54% by week 5 (this does not include the 451 participants who did not provide a valid email address). Results from Google analytics indicate that at week 1, there were 9170 unique views of the URL, which provided the detailed instructions for the week. This dropped by week 5 to 3539 unique views.

Discussion

The results of this audit indicate that physiotherapy students and physiotherapists are interested and willing to participate in MOOCs on SCI. This is important to know because physiotherapy students’ and physiotherapists’ acceptance of this form of learning is probably indicative of other health-care professionals’ acceptance of the same style of learning. MOOCs may therefore provide a way of educating all types of health-care professionals about SCI. The model used for the physiotherapists could be rolled out to other health-care professionals in SCI because the content of MOOCs could be based on the modules already developed by the International Spinal Cord Society and freely available at www.elearnSCI.org.

The results of this audit do not indicate the effectiveness of MOOCs for learning. They only indicate students’ and physiotherapists’ willingness to participate in this style of learning and their satisfaction with the learning experience. A randomised controlled trial carried out as part of this MOOC involving a small subset of physiotherapy students from Bangladesh (n=48) showed that these students did not gain more knowledge (mean between group difference and 95% confidence interval (CI), 1 point (−1 to 3) on a 0–20 point scale).13 Nor did they feel more confident to treat a person with SCI or have better satisfaction with the learning experience compared with students who were asked to progress through the physiotherapy-specific module on www.elearnSCI.org at their own pace. These students however may not be representative of all students because English was their second language and most were trying to access the Facebook discussion from their mobile phones with limited internet connectivity. These two factors may have restricted their participation. In addition, there were high levels of satisfaction and confidence in both groups at the end of the trial period, indicating ceiling effects with these two outcomes, which may have masked between-group differences. Nonetheless, MOOCs will never fully replace a skilled teacher providing face-to-face education in a classroom situation. Nor will MOOCs provide students with practical experience. However, they may provide a consistent learning experience to very large numbers of physiotherapy students and physiotherapists from many countries around the world where educational opportunities about SCI may be limited.

The completion rate of our MOOC was 41% (1506 students completed the final assessment from a total of 3523 students who enrolled). This is notably higher than the 10% retention rate typically reported in the literature for MOOCs. Poor retention in MOOCs is widely commented upon.3,5, 6, 7, 8, 9, 10, 11 Some argue that poor retention is problematic and reflective of the inadequacies of MOOCs compared with traditional face-to-face teaching, whereas others argue that poor retention merely reflects a lack of true commitment to the course from students when they sign up. MOOCs are largely free and therefore people with a passing curiosity may be tempted to register for a MOOC. Our MOOC may have attracted a lot of people who were just curious and interested in seeing how the educational content was delivered with no real intention of completing it. MOOCs are new to physiotherapists, thus there may have been a high level of curiosity. However, regardless, our retention rate was fairly good. This may partly be because participants earned Continuing Education Credits from the World Confederation for Physical Therapists and received a completion certificate. Alternatively, may be participants simply enjoyed the learning experience or highly valued the opportunity to increase their knowledge and skills in this area. No doubt participation and completion rates could be further increased if academic institutes incorporated the MOOC into their curriculums and results were used as part of students’ formal assessments.

Feedback from the evaluations indicated that those who completed the MOOC enjoyed it (see Figure 1). However, one aspect of the MOOC that was not enjoyed by all participants was the Facebook discussion. This was very popular with some and very unpopular with others (see Tables 4 and 5). Those who enjoyed the discussions on Facebook typically commented on valuing the opportunity this provided to connect with other course participants from other countries. They typically stated that this broadened their perspective and heightened their understanding of issues around the world. One of the challenges with the Facebook group was the large number of posts. Some discussion topics attracted close to a 1000 posts within a week. In some weeks, up to four discussion topics were set as part of the course and participants were free to add their own discussion topics. Thus, this equated to several thousand posts per week. This was too much for participants to read and the format was not conducive to a meaningful discussion between participants. In addition, it was difficult for the teachers to answer participants’ specific questions because questions and answers were often lost in the long discussion threads. However, regardless, the set discussion topics probably at least drew participants’ attention to specific issues. For example, one of the discussion topics for week 1 was about pressure ulcers (see Table 1). The mere act of seeing hundreds of posts on this topic must have at least made participants aware of the gravity of the problem.

An important limitation of this audit is that no data are available on those who registered but did not complete the course. This is a source of bias because those who did not complete the course are probably not representative of those that did. The other important limitation of this audit was our inability to monitor accurately how much of the learning material participants were moving through. We could indirectly estimate this by looking at the number of people who attempted the multiple choice questions at the end of each lesson in www.elearnSCI.org. However, participants may have moved through lessons and not done the multiple choice questions, or they may have done the multiple choice questions without moving through the lessons. Arguably, it does not matter how much of the content participants moved through provided they did well in the final post-MOOC knowledge assessments, which was the case for those who completed them.

In all, this audit does not provide answers about the effectiveness of MOOCs; however, it does open the discussion about possible strategies that could be used to educate the SCI workforce around the globe. It is probably not correct to assume that health-care professionals receive sufficient training in SCI as part of their undergraduate or graduate programs. Spinal cord injuries is often considered a highly specialised area and therefore not given high priority in course curriculums. In addition, educational institutes often struggle to provide appropriately qualified academics and teachers with expertise in SCI. The modules developed at part of www.elearnSCI.org are clearly an important step in this direction. However, now the challenge is getting these modules embedded within formal undergraduate and graduate training programs and encouraging and supporting people to complete them. MOOCs may provide a partial solution with the added benefit of providing students the opportunity to make connections with colleagues from other countries through social media.

DATA ARCHIVING

There were no data to deposit.