The European Center for the Development of Professional Education and Training defines electronic learning (e-learning) as an “instructional model, based on the use of information and communication technologies (ICT), to acquire knowledge, know-how, information, values, skills and competences through the Internet” (1). E-learning encompasses various formats and hybrid methodologies, such as programming systems, the Internet, CD-ROMs, real-time education via personal computers (PCs), and other electronic or interactive devices.

E-learning has become integral part of science and practice, including in medicine and health care, and education in these fields (2). During the COVID-19 pandemic, digitalization of educational materials became essential, and electronic education was widely adopted in medical universities. Therefore, over recent years, we have prepared a digital library of educational materials in the field of Physical Medicine and Rehabilitation.

The Council of the European Union of Medical Specialists defines the Medical Act as follows: “The medical act encompasses all the professional actions, e.g., scientific, teaching, training and educational, clinical and medico-technical steps, performed to promote health and functioning, prevent diseases, provide diagnostic or therapeutic and rehabilitative care to patients, individuals, groups or communities in the framework of the respect of ethical and deontological values. It is the responsibility of, and must always be performed by a registered medical doctor/physician or under his or her direct supervision and/or prescription” (3).

The quality of medical and healthcare services is essential, and continuous education is necessary. To support high standards of medical care, the European Union of Medical Specialists (UEMS) has developed normative documents for specialization of medical doctors and for Long-life learning (LLL) in the European Community: standards for promotion of good medical care (4), training medical specialists (5), continuing medical education (6), etc.

Physical and Rehabilitation Medicine (PRM), also known as physiatry, is a medical specialty that utilizes various physical modalities to improve the quality of care and patients’ quality of life. According to the European Union of Medical Specialists – PRM Section, it is an „independent clinical medical specialty, oriented to the promotion of physical and cognitive functioning, activities, participation and changes in personal factors and environment” (7). Medical doctors – PRM specialists are responsible for the management of the prevention, diagnostics, treatment and rehabilitation of patients with health-related disability and co-morbidity of all ages (7, 8).

The White Book on Physical and Rehabilitation Medicine defines the primary objective of PRM as optimizing social participation and enhancing patients’ quality of life (8). This includes supporting patient to achieve possible levels and patterns of autonomy and independence, including participation in professional, social and leisure activities, which are part of their human rights. Tasks of PRM are as follows: treating existing pathology; reducing disability; preventing and managing complications; enhancing functioning and activity; and encouraging patient’s participation in various activities (8, 9).

Rehabilitation is a functional therapy, based on detailed functional assessment. The World Report on Disability outlines rehabilitation goals as follows: preventing loss of function; slowing the rate of loss of function; improving or restoring function; compensating the lost function; and maintaining current function (10). Modern rehabilitation adopts an integrative and holistic approach to patient care, based on the International Classification of Diseases (ICD) (11); the International Classification of Functioning, disability and Health (ICF) (12), and clinical principles (13).

In clinical rehabilitation practice, we apply a complex algorithm, including a detailed functional evaluation and a synergic combination of different natural and preformed physical modalities (the “rehabilitation puzzle”). Natural physical factors include procedures of physical therapy (active and passive movements); hydrotherapy, balneotherapy and thalassotherapy (baths and pools with water, mineral and seawaters; jets; underwater exercises and underwater massage); climatotherapy; occupational therapy or ergotherapy (activities of daily life, professional activities). From the group of preformed modalities, we apply procedures of electrotherapy (electric currents and electrostatic field), magnetotherapy (magnetic field), ultrasound, photo-therapy (infrared, visible or ultraviolet beams of light, laser), among others.

The World Report on Disability of the World Health Organization (WHO) and of the World Bank categorizes rehabilitation measures into three categories: rehabilitation medicine, therapy and assistive technologies (9). The rehabilitation process is carried out by a multidisciplinary and multiprofessional rehabilitation team, which includes medical doctors of various specialties, nurses, physiotherapists, occupational therapists, etc. Figure 1 presents the members of this rehabilitation team, with certain members highlighted in color to indicate their inclusion in our study.

We adapt the educational process to the needs and expectations of different members of the rehabilitation team: medical doctors, physiotherapists, nurses, medical assistants, and midwives – during the process of their graduate and post-graduate education (as students, residents, and participants in long-life learning courses).

We consider basic principles of learning and e-learning (2, 14–16). We use the ABCD-model for learning, which emphasizes education, adapted to the audience (A) and its behavior (B), oriented toward the condition (C) and the degree (D). At every stage, we inform learners of our expectations, regarding their theoretical knowledge and practical skills. We provide clear instructions for education and vocational training, and we encourage the practical application of theoretical knowledge.

In clinical rehabilitation practice and in the process of education and training, we apply the SMART model: setting goals, which are specific (S), measurable (M) and attainable (A); with relevant (R) results and a time-bound (T) approach.

We have systematically introduced elements of electronic (e-) learning into the clinical practice of various educational disciplines – in the areas of basic principles of physical medicine and specialized rehabilitation (17–19). In the general section, we included topics such as: kinesiological analysis, manual therapy, balneology, thalassotherapy, ergotherapy (occupational therapy), and grasp and gait rehabilitation. In the clinical section, we covered: neurological and neurosurgical rehabilitation, pediatric neurorehabilitation, cardiorehabilitation, physical prevention, prevention and rehabilitation in Obstetrics and Gynecology, rehabilitation for SARS-CoV2 and Neuro-COVID, rehabilitation for PC-induced health issues, burnout prevention and rehabilitation, rehabilitation using neurorobots and virtual reality, and more. Current article summarizes the results of implementing electronic learning in all areas of PRM and evaluates its effectiveness and impact on the professional competencies of different types of the rehabilitation staff.

The objective of current article is to prepare an electronic library with educational materials in the field of physical medicine, physical therapy and rehabilitation, and to evaluate comparatively the impact of including this digitalized repository in the education of students and trainees in the field – on their professional competencies (theoretical knowledge and practical skills).

The null hypothesis (H0) is that the application of elements of electronic learning will not influence the quality of education of members of the rehabilitation team. The alternative hypothesis (H1) is that the use of an electronic repository will improve the professional capabilities of our learners.

A comparative study design was used to evaluate the impact of the digitalized repository on professional competences of our students and trainees. For this, we created an electronic (e-) repository of digitized classic manuals and we prepared contemporary books, including principal elements of the European Curriculum for physical medicine and rehabilitation. These educational materials were implemented in the process of education of students, PRM trainees, and in the long-life learning programs for the members of the rehabilitation team (physicians specializing in PRM, physiatrists, physiotherapists, nurses, midwives, and medical assistants). We developed tests to assess learners’ level of theoretical knowledge. For practical skills assessment, quizzes based on clinical case scenarios were included. Finally, we conducted face-to-face both theoretical and practical exams, using the standard grading scale in our country (from Excellent 6 to Poor 2). After the exams, but before sharing their results, our students and trainees completed questionnaires for assessment of their opinions on the educational materials of the e-library and the realized educational course (lectures and practical exercises) – using a 7-levels Likert’s scale (from strongly positive to strongly negative judgment). This is a personal investigation (anonymous for the assessment of learners’ opinion), and includes a detailed analysis of results from fully completed studies and questionnaires (see Figure 2).

The digital repository includes e-books on different topics, related to PRM, containing theoretical data, practical issues, and case reports with videos of real patients – predominantly in Bulgarian language and some manuals in English (20–25). In the field of basic physiatry, we included books on fundamental topics: kinesiological and pathokinesiological analysis, functional evaluation; physiotherapy (active exercises, soft-tissue techniques), ergotherapy (activities), balneotherapy (mineral baths and peloids, underwater gymnastics), manual therapy (tractions, mobilizations, manipulations), preformed physical factors (electric currents, magnetic fields, ultrasound, light, laser, etc.). In the area of special physiatry, we involved manuals on: neurological and neurosurgical rehabilitation, orthopedic and traumatologic rehabilitation, rheumatologic rehabilitation, cardiac and cardiosurgical rehabilitation, robotic neurorehabilitation, etc. We added some basic publications and interesting articles on the topic (6–8, 12, 26, 27). Figure 3 clarifies the creation of the digital repository (digitalization of classic manuals and preparation of new books and videos on different topics in the area of physical medicine, physical therapy and rehabilitation).

Figure 4 presents the details of the questionnaire assessing the learners’ opinion on the e-library – using a Likert’s scale with 7 levels.

We utilized the electronic books during the education of a total of 1,186 learners: graduate studies of students in Bachelor’s degree programs (Physiotherapy, Nursing, Midwifery, Medical assistants) and Master’s degree programs (Physiotherapy, Medical rehabilitation and balneology), during the postgraduate training of medical doctors—residents in Physical and Rehabilitation medicine (PRM); and during the post-graduate long-life learning courses for physiatrists, physiotherapists, nurses, medical assistants, midwives.

For the current study, we applied different methods: screening, questionnaires, analysis of documents, and statistics.

A bank with approximately 1,000 questions for evaluation of professional competences in the field of rehabilitation was created. Different groups of tests are oriented to different types of staff in rehabilitation field (students and workers): medical doctors – PRM specialists and residents, students and health professionals in Physiotherapy (Kinesitherapy, Medical Rehabilitation and Ergotherapy, Medical rehabilitation and Balneotherapy), Nursing, Midwifery, Medical assistants. We also conducted an exploration of students’ opinion and workers’ opinion on some organization problems of Bulgarian rehabilitation school and practice.

The questionnaire was proposed to the cited target groups. Here we refer only to the results of the learners’ opinions from fully answered questionnaires (1,052 responders of a total of 1,186 participants in the experimental groups).

The final statistical evaluation of results was conducted using the statistical package SPSS, version 19: with options for comparing two samples using parametrical analysis of variances ANOVA and non-parametrical distribution and correlation analysis, as follows: t-test (t-criterion, p value), Signed test, Signed rank test, Kolmogorov – Smirnov test, Mann – Whitney (Wilcoxon) W test (W median). For statistically significant effects, we considered results with a value of p < 0.01.

Figure 7 presents the distribution of grades (evaluation of principal bases of rehabilitation—theoretical knowledge and practical skills) among different team members: Bachelor’s and Master’s students in Physiotherapy, those in Healthcare, and working specialists during LLL-courses; with a comparison between control /C/ and experimental groups /E/.

The difference between control groups (traditional education) and experimental groups (Exp) is significant.

Next, Figure 8 presents the results of the evaluation of competencies in the fields of special rehabilitation (Reh/Rehab): neurological and neurosurgical (Neuro-Reh), orthopedic and traumatologic (OT-Rehab), cardiac and cardiosurgical (Cardio-Reh), and rheumatological rehabilitation (Rheuma-Reh). Here, we present the data of students in Master’s degree, medical doctors, and physiotherapists of LLL-courses. The comparative analysis of results from control and experimental (Exp) groups demonstrated significant differences.

The analysis of case studies is significantly better in groups of postgraduate education and LLL-courses: medical doctors – trainees in PRM and physiotherapists. Results are presented in Figure 9. In this type of evaluation we use quizzes – clinical cases with maximal results of 10 points.

The theoretical knowledge and practical skills of medical doctors and physiotherapists are considerably better in the area of rehabilitation of neurological and orthopedic conditions. These are the most frequent patient populations and, consequently, receive the best treatment. Cardiac and cardio-surgical rehabilitation is a specific field, not sufficiently covered during university courses.

We analyzed the learners’ opinion on the quality of the digitalized repository and its efficacy for the level of professional competences using a Likert type scale with seven echelons (from Strongly agree to Strongly disagree). Table 2 and Figure 10 present the obtained results from the fully completed questionnaires of 1,052 responders from the experimental groups.

Practically more than 99.6% of learners expressed satisfaction with the electronic repository (the responses of 1,004 participants or 95.44% are strongly positive; 33 or 3.14% have a positive opinion, Maybe yes is the answer of 11 or 1.05%). Three participants are indifferent (0.28%). One answer is Maybe No (0.000950%). There are no negative or strongly negative opinions.

We asked our students and trainees about possible topics that are interesting to them. Figure 11 demonstrates the paths for amplification of the e-repository. The most interesting themes for our learners include: neurorehabilitation, neurorobots and virtual reality, grasp and gait rehabilitation, etc.