Continuing professional development to strengthen stroke rehabilitation: learning outcomes from Myanmar

Abstract

Background

Stroke is the second leading cause of global disability with the majority of stroke-related disabilities occurring in low- and middle-income countries. In Myanmar, ongoing political instability and healthcare disruption have further limited access to stroke rehabilitation services. This study evaluated a contextually tailored continuing professional development program designed to strengthen evidence-based stroke rehabilitation knowledge, skills, and clinical implementation among physiotherapists in Myanmar.

Methods

This mixed methods, quasi-experimental study used convenience sampling to recruit rehabilitation professionals participating in a blended learning stroke rehabilitation program in Myanmar. The program combined online coursework, synchronous mentoring, and in-person clinical skills training. Training effectiveness was evaluated using the Kirkpatrick Model across the domains of reaction, learning, behavior, and results. Participants completed pre-training, post-online, post-in-person, and six-month follow-up surveys assessing self-perceived knowledge, skills, and implementation of evidence-based stroke rehabilitation techniques. Quantitative data were analyzed using Kruskal-Wallis and Mann-Whitney U tests with Bonferroni correction. Focus group interviews were conducted six months following training and analyzed using thematic analysis. Quantitative and qualitative findings were integrated during interpretation to better understand implementation within the Myanmar context. Ethical approval was obtained from the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.

Results

Seventeen rehabilitation professionals participated in the online training and 16 physiotherapists completed the in-person clinical skills component. Seven participants participated in focus group interviews six months later. Participants demonstrated significant improvements in self-perceived knowledge and skills related to evidence-based stroke rehabilitation, particularly for interventions requiring minimal equipment. Follow-up surveys indicated integration of evidence-based assessment and treatment approaches into clinical practice. Qualitative findings contextualized these changes and identified four themes: challenges in rehabilitation perception, need for enhanced training in fine motor skills, resourceful adaptation of techniques for low-resource settings, and the importance of a learning community. Integrated findings demonstrated that participants adapted evidence-based rehabilitation concepts using locally available resources and peer support networks.

Conclusions

Contextualized training approaches emphasizing adaptability, peer learning, and resource-conscious implementation may support the application of evidence-based stroke rehabilitation practices in LMICs affected by workforce and health system constraints.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14917-0.

Background

Stroke is the second leading cause of global disability, with 87% of stroke-related disabilities occurring in low- and middle-income countries (LMICs) [1]. In these countries, access to acute stroke interventions is often limited, including emergency medical transport, neuroimaging services, and evidence-based interventions such as thrombolysis, making effective post-stroke rehabilitation the most viable option for supporting recovery [2, 3]. Barriers to accessing rehabilitation include systemic issues such as the absence of national guidelines, low prioritization of rehabilitation services, and a shortage of rehabilitation professionals [2]. While high-income countries (HICs) benefit from a range of rehabilitation options and skilled specialists, LMICs face a significant gap [4]. On average, LMICs have approximately 10 skilled rehabilitation experts per one million people, whereas HICs have over 400 occupational therapists, 900 physical therapists, 400 speech therapists, and 20 physical medicine and rehabilitation physicians per one million people [2]. Additionally, patient-related factors such as limited health literacy, financial constraints, and transportation issues further hinder access to rehabilitation services [2].

Resource-intensive rehabilitation models from HICs may not be feasible in low-resource settings. Therefore, it is crucial to implement rehabilitation services that are both effective and sustainable within the context of available resources, incorporating adaptable components from high-resource settings [5]. Contextual challenges including language barriers, cultural differences, and accessibility issues often become more pronounced in regions with geopolitical instability [5]. In Myanmar, humanitarian and healthcare access has been severely constrained since the military coup in 2021 [6]. Over the past four years, attacks and threats against healthcare workers and facilities have led to the arrest or death of hundreds of health professionals and the closure of many hospitals and clinics [6, 7]. The higher education sector has also been affected, with Universities closed due to faculty shortages arising from participation in the Civil Disobedience Movement, thereby limiting training of future health workers [8]. According to the United Nations, the healthcare system in Myanmar is in a state of collapse [9]. For the approximately 70% of the population living in rural areas, whom often face compounded barriers including limited health knowledge, lack of access to medical providers, and unreliable electricity, these systemic challenges are particularly amplified, further restricting access to rehabilitation services, continuity of care, and opportunities for ongoing professional support for healthcare providers [10].

The development of robust rehabilitation services and programs for individuals following stroke is critical in Myanmar where medical services such as mechanical thrombectomy and thrombolysis is severely limited. These services have been shown to reduce post-stroke disability, especially for individuals with ischemic stroke due to large vessel occlusion [11, 12]. The recently published Mechanical Thrombectomy Global Access for Stroke (MT-GLASS) study found that Myanmar is one of seven countries in the world which lack access to mechanical thrombectomy procedures [11]. Additionally, a recent systematic review found that due to cost and limited numbers of neurologists, there is only an 8.1% rate of thrombolysis for individuals hospitalized with acute ischemic strokes in LMICs [12]. Given this disparity in access to medical care, stroke survivors in LMICs are frequently left with more profound post-stroke disability to overcome through their rehabilitation. Although previous studies have described barriers to stroke rehabilitation access in LMICs and emphasized the importance of workforce development, limited research has examined continuing professional development models designed to support implementation of evidence-based stroke rehabilitation in fragile and resource-constrained settings [2, 5]. Recent literature has highlighted the need for rehabilitation education approaches that are adaptable, locally relevant, and feasible within environments affected by workforce shortages, infrastructure limitations, and disrupted healthcare systems [2, 5].

Accordingly, a continuing professional development program emphasizing adaptable, evidence-based stroke rehabilitation strategies was designed to support rehabilitation professionals working within the complex clinical realities of Myanmar. Evaluation of continuing professional development programs requires assessment beyond immediate learner satisfaction to understand whether knowledge and skills are translated into clinical practice. The Kirkpatrick Model is a widely used framework for evaluating training effectiveness across four domains: participant reaction, learning, behavior change, and broader results associated with implementation in practice [13]. This framework was selected to guide evaluation of the training program because it allows assessment of both educational outcomes and perceived application of learning within the complex rehabilitation context of Myanmar.

Methods

The purpose of this study was to evaluate the effectiveness of this contextually tailored training program for rehabilitation professionals in Myanmar by assessing participants’ satisfaction with the training, perceived changes in knowledge and skills, application of learned techniques in clinical practice, and experiences implementing evidence-based rehabilitation approaches within a resource-constrained environment. The training program was tailored to the Myanmar context during program development through adaptation of content and delivery methods to address limited rehabilitation resources, intermittent electricity access, workforce shortages, rural practice settings, and restricted access to international clinical educators following the 2021 military coup [5–10]. This study used a convergent mixed methods design incorporating quantitative surveys and qualitative focus group interviews to evaluate the effectiveness and contextual implementation of a stroke rehabilitation training program in Myanmar. Quantitative and qualitative findings were integrated during interpretation to provide a more comprehensive understanding of participants’ learning experiences and application of evidence-based rehabilitation practices. A mixed methods approach was selected to capture both measurable learning outcomes and the contextual factors influencing implementation of rehabilitation practices in a resource-constrained environment.

Training program

The training program was collaboratively developed by an international team of physiotherapists and rehabilitation educators with expertise in neurologic rehabilitation, rehabilitation education, and continuing professional development. The development team included clinicians and educators affiliated with academic institutions and international rehabilitation education organizations with prior experience delivering rehabilitation training in low-resource settings. Program content was informed by international stroke rehabilitation clinical practice guidelines and adapted to the Myanmar context through consultation with local rehabilitation providers regarding resource limitations, workforce challenges, clinical responsibilities, and barriers to implementation [14–20]. Learning objectives focused on improving participants’ understanding of stroke rehabilitation principles, evidence-based assessment and treatment approaches, clinical decision-making, and the adaptation of rehabilitation strategies for resource-constrained environments.

The target participants were rehabilitation professionals currently involved in the management of patients following stroke in Myanmar. Participants were recruited through professional rehabilitation networks and partner organizations involved in rehabilitation education and service delivery within the country. A convenience sampling approach was used due to the limited rehabilitation workforce and ongoing political and infrastructure disruptions affecting communication and travel within Myanmar. Most participants were physiotherapists trained at the bachelor’s level who had previous clinical experience treating patients following stroke; however, formal postgraduate training in neurologic rehabilitation and access to continuing professional development opportunities were limited.

The training program consisted of a comprehensive four-week curriculum providing an overview of physiotherapy practice related to common neurological impairments following stroke to develop a foundation of knowledge that would enable participants to assess and manage individuals within the constraints of the resources available in Myanmar. The program used a blended learning approach with three key components: online coursework, synchronous mentoring, and hands-on in-person training. Participants engaged in a series of four online courses, each lasting approximately four hours, and benefited from two synchronous mentoring sessions where they could seek guidance and reflect on their learning. Course topics were divided into four modules: (1) Epidemiology, Risk Factors, Anatomy, and Clinical Presentation, (2) Assessment of Stroke including Outcomes Measures, (3) Management of Stroke including Clinical Guidelines, and (4) Specific Therapeutic Interventions.

At the beginning of the program a virtual community of practice was established. The platform was a community-owned platform managed by Physiopedia designed to support collaboration across the rehabilitation sector. The platform enabled users to create and participate in community groups. Its capabilities included peer discussion, resource sharing, networking, and facilitating communities of practice around specific rehabilitation topics and areas of interest. It was also a convenient way to introduce the participants to the program mentors and communicate announcements and key tasks to complete throughout the training. Throughout the four-week program, participants shared patient videos and case studies asynchronously through the online community platform. Cases were discussed in both small-group and larger group formats during scheduled synchronous mentoring sessions, where mentors and participants collaboratively reviewed assessment findings, treatment approaches, contextual challenges, and adaptations for resource-limited environments.

The in-person training component, conducted in both Yangon and Hpa-an, allowed participants to practice hands-on skills related to stroke management. These areas were chosen based upon location of the participants and for access to electricity which was constrained due to scheduled black outs due to the ongoing conflict and damaged infrastructure. Due to an increase in conflict in the region of Hpa-an and flooding in the region at the time of the training, two separate dates were provided to avoid the need for participants to travel due to safety concerns. International trainers participated remotely via Google Meets. Multiple laptop computers were set up to enable visualization of participants and provide real-time feedback as they practiced the hands-on element of the training.

Practical skills emphasized low-technology, evidence-based interventions that could be feasibly implemented within the resource constraints commonly encountered in Myanmar. Selection of techniques was informed by international stroke rehabilitation clinical practice guidelines, and consultation with local rehabilitation providers regarding commonly encountered clinical challenges and available resources [14–20]. Prior to the in-person training, participants completed online modules that introduced the theoretical foundations, clinical reasoning, and demonstration of the techniques through recorded instructional materials and case discussions. Participants were also provided with written educational materials and step-by-step guidance documents to support skill practice and later clinical implementation.

Program assessment and data collection

This study (IRB No. 21399) was reviewed by the Johns Hopkins School of Public Health (JHSPH) Institutional review board and determined to be exempt. Informed consent and confidentiality practices were followed. Training effectiveness was evaluated using the four domains of the Kirkpatrick Model [13]. At the first level, reaction, participants’ immediate responses to the training, including satisfaction and engagement, were gathered. Learning, the second level, involved assessing participants perceived acquisition of knowledge, skills, or competencies following completion of the training program. The behavior level explored the extent to which new knowledge and skills were applied in professional practice six months following completion of the program. The results domain explored participants’ perceptions of how the training influenced their clinical practice, including implementation of evidence-based assessment and treatment approaches, adaptation of techniques to resource-constrained settings, and dissemination of knowledge and skills to colleagues through formal and informal peer learning. The six-month timeframe allowed participants sufficient time to apply newly acquired knowledge and skills within clinical practice settings while minimizing potential participant attrition associated with longer follow-up periods in a context affected by ongoing political instability and infrastructure disruption.

To evaluate these domains, structured surveys and a semi-structured interview guide were developed specifically for this study, as no existing tools were identified that were appropriate for the Myanmar context or aligned with the training content. The survey assessed changes in knowledge and confidence across the three training stages (pre-online, post-online, post-in-person, and six months post training), as well as participants’ perceptions of the relevance of the training content to their clinical practice and the feasibility of applying the learned techniques within their local clinical environments. The semi-structured interview guide used in the follow-up focus groups explored clinical implementation of the knowledge and skills learned through the training. All surveys and the semi-structured interview guide can be found in Appendices A-D.

Data on knowledge acquisition were analyzed using non-parametric tests due to the ordinal nature of Likert scale data and the small sample size. The Kruskal-Wallis test was used to detect significant differences across the three time points (pre-online, post-online, and post-in-person training). Mann-Whitney U tests were used for direct comparisons between specific time points. A Bonferroni correction was applied to control for Type I errors due to multiple comparisons. This conservative approach ensured that observed differences were unlikely to be due to chance alone. All statistical analyses were performed using SPSS version28.

Focus group interviews were also conducted six months following completion of the program. Interviews were conducted in English with the assistance of a healthcare interpreter knowledgeable in the subject and were audio recorded and transcribed. Participants were asked about their experiences implementing learned techniques in clinical practice and sharing the knowledge and skills acquired (Kirkpatrick Level 4). Thematic analysis was applied to assess the data [21]. The constant comparative method was utilized for primary coding, followed by secondary cycle coding to identify patterns and themes. A second researcher reviewed the themes to ensure credibility. This study was approved by an institutional review committee and the subjects provided informed consent. Subjects had the opportunity to participate in both or either the longitudinal surveys or focus group interviews.

Results

Seventeen rehabilitation professionals participated in the online component of the training program including 16 physiotherapists trained at the bachelor’s level. All physiotherapists were able to attend the in-person training. Demographic information for participants can be found in Table 1. The participants indicated satisfaction with the in-person training (Table 2). Self-assessment surveys on knowledge and skills related to early intervention programs were administered at three stages: before starting the online course, after completing the online course, and following the in-person training. Survey frequencies for each item are listed in Tables 3 and 4. Participants showed significant improvement in their self-perception of knowledge and skills that required minimal or no equipment (tactile cues, brushing, tapping), as analyzed by the Kruskal-Wallis test and Mann-Whitney U comparisons (Tables 3 and 4). Six months after completing the training, participants reported integrating the skills into their clinical practice. They were able to differentiate between types of stroke, choose stroke-appropriate assessment scales and outcome measures, implement clinical practice guidelines, and select suitable treatment options.

Table 1.

Demographic information

Demographic Information	Pre Online Training (n = 14)	Post Online Training (n = 13)	Post Onsite Training (n = 15)	6-months post Onsite Training (n = 11)
Gender
Male	1	1	0	2
Female	13	12	15	9
Prefer not to say	0	1	0	0
Profession
Physical Therapist	13	11	15	9
Occupational Therapist	0	0	0	0
Speech and Language Therapist	0	0	0	0
Prosthetist and Orthotist	1	1	0	2
Employment
Academic Institution	0	0	0	0
Non-governmental Organization	7	6	8	6
Hospital	2	3	3	2
Rehabilitation Clinic	2	2	1	1
Other (Freelance, Red Cross)	2	2	3	2
Did not respond	1

Table 2.

In-person training satisfaction survey (n = 15)

Likert scale of 1–5 with 1 = extremely dissatisfied and 5 = extremely satisfied	Mean ± SD
Training Content and Materials
The online coursework and onsite instruction complemented each other well	4.73 ± 0.46
The online coursework adequately prepared me for the onsite training	4.53 ± 0.52
I learned skills and concepts that I will be able to apply in my practice	4.73 ± 0.46
This training programme was relevant to me and my professional role	4.87 ± 0.35
Training and Mentoring Team
The team was well-prepared for the onsite training	4.73 ± 0.46
The team was knowledgeable in the training topic	4.87 ± 0.35
The team showed an interest in helping participants learn	4.73 ± 0.46
The training materials were presented in a way that helped me understand the underlying concepts	4.40 ± 0.51
Training Logistics
The location of the venue was suitable for the training	4.53 ± 0.52
The length of the training was adequate	3.73 ± 0.46
The quality of the food service was adequate	3.73 ± 0.46
The availability of patients was suitable for this training	4.53 ± 0.52
The technology of the presentation was suitable for this training	4.40 ± 0.51
The training room was comfortable	4.40 ± 0.51
The training supplies (paper, pen, handouts etc.) were adequate	3.73 ± 0.46
Overall Impressions
This onsite training has improved my confidence in my current role.	4.53 ± 0.52
I would highly recommend this clinical skills training programme to others.	4.73 ± 0.46

Table 3.

Changes in self-perceived knowledge of stroke rehabilitation concepts across training phases

Concepts	Pre Online Training Mean ± SD (n = 14)	Post Online Training Mean ± SD (n = 13)	Post Onsite Training Mean ± SD (n = 15)	Kruskal Wallis	Pre Online to Post Online Mann-Whitney U	Pre Onsite to Post In-Person Mann- Whitney U	Pre Online to Post In-Person Mann-Whitney U
I can identify various risk factors for stroke that can be modified or avoided to reduce risk.	3.71 ± 0.825	4.25 ± 0.866	4.57 ± 0.514	0.010	0.054	0.351	0.003*
I can describe the different characteristics of the two main types or classifications of stroke; ischemic and hemorrhagic.	3.62 ± 0.961	4.58 ± 0.515	4.60 ± 0.507	0.004*	0.007	0.932	0.004*
I can describe several clinical presentations of a stroke and the resulting deficits.	3.15 ± 0.987	4.08 ± 0.515	4.29 ± 0.469	0.001*	0.008	0.319	< 0.001*
I can compare and contrast several stroke assessment scales used to assess and individual following stroke such as the National Institutes of Health Stroke Scale (NIHSS) and Scandinavian Stroke Scale (SSS).	2.29 ± 0.751	3.67 ± 0.651	3.87 ± 0.516	< 0.001*	0.002*	0.504	< 0.001*
I can compare and contrast various Outcome Measures used to assess individuals following stroke such as the Barthel Index, Berg Balance Scale and the FIM	2.85 ± 1.07	3.83 ± 0.835	4.27 ± 0.458	< 0.001*	0.018	0.135	< 0.001*
I can discuss the benefits and limitations of clinical guidelines used in Stroke Management	2.69 ± 0.751	4.08 ± 0.515	3.93 ± 0.616	< 0.001*	< 0.001*	0.487	< 0.001*
I can identify when brain imaging should be performed immediately for patients with persistent neurological symptoms.	2.62 ± 0.870	3.75 ± 0.622	4.00 ± 0.756	< 0.001*	< 0.001*	0.461	< 0.001*
I can select the most appropriate treatment options for an individual following stroke	3.15 ± 0.801	4.17 ± 0.577	4.29 ± 0.726	0.002*	0.003*	0.566	0.002*
I understand the importance of Physiotherapy in secondary prevention of stroke.	3.77 ± 1.01	4.42 ± 0.900	4.50 ± 0.650	0.073	0.066	1.00	0.042
I can describe the role of a physiotherapist working within a multidisciplinary team with an individual post stroke.	3.54 ± 0.877	4.42 ± 0.793	4.43 ± 0.514	0.011	0.019	0.774	0.006

Data are presented as mean scores on a 5-point Likert scale, with higher scores indicating greater perceived confidence

One participant did not complete all questions on the post online and post onsite training survey

* Indicates statistical significance at p < 0.05 before Bonferroni correction. Following Bonferroni correction, significance was established at p ≤ 0.005

Table 4.

Changes in self-perceived confidence in stroke rehabilitation techniques across training phases

Therapeutic Approach	Pre Online Training Mean ± SD (n = 14)	Post Online Training Mean ± SD (n = 13)	Post Onsite Training Mean ± SD (n = 15)	Kruskal Wallis	Pre Online to Post Online Mann- Whitney U	Pre Onsite to Post Onsite Mann- Whitney U	Pre Online to Post Onsite Mann- Whitney U
Balance Training	3.71 ± 0.825	4.08 ± 0.641	4.53 ± 0.516	0.013	0.236	0.058	0.005
Brushing	2.64 ± 0.842	3.69 ± 0.751	3.86 ± 0.663	< 0.001*	0.003	0.659	< 0.001*
Cardiovascular Training	2.93 ± 0.829	3.83 ± 0.718	3.85 ± 1.14	0.016	0.012	0.685	0.027
Functional Training	3.29 ± 0.914	3.83 ± 0.718	4.33 ± 0.724	0.007	0.056	0.102	0.004
Joint Compression	3.21 ± 0.699	4.15 ± 0.376	4.07 ± 0.829	< 0.001*	< 0.001*	0.952	0.005
Massage	2.57 ± 0.938	3.54 ± 0.660	3.71 ± 0.611	< 0.001*	0.003	0.416	< 0.001*
Mirror Training	2.85 ± 0.801	3.38 ± 0.650	3.80 ± 1.01	0.024	0.073	0.178	0.013
Neurodevelopment training (NDT)/ Neuro-IFRAH	2.71 ± 0.726	3.77 ± 0.599	4.00 ± 0.655	< 0.001*	0.007	0.341	< 0.001*
Orthotic Assessment	3.29 ± 0.726	3.54 ± 0.660	4.08 ± 0.760	0.013	0.332	0.029	0.006
Pain Management	2.79 ± 0.893	3.62 ± 0.650	3.77 ± 0.725	0.027	0.005	0.508	0.020
Passive Stretching	3.79 ± 0.699	4.42 ± 0.515	4.50 ± 0.519	0.010	0.016	0.667	0.005
Positioning	3.93 ± 0.730	4.23 ± 0.599	4.47 ± 0.516	0.098	0.281	0.301	0.032
Strength Training	3.64 ± 0.745	3.92 ± 0.641	4.38 ± 0.506	0.021	0.348	0.062	0.008
Tactile Cues	3.00 ± 1.08	3.67 ± 0.651	4.46 ± 0.519	< 0.001*	0.083	0.005	< 0.001*
Tapping	2.46 ± 0.660	3.77 ± 0.599	3.73 ± 0.458	< 0.001*	< 0.001*	0.932	< 0.001*
Therapeutic Handling	3.00 ± 0.877	3.69 ± 0.751	4.33 ± 0.617	< 0.001*	0.034	0.022	< 0.001*
Verbal Cues	3.23 ± 0.927	3.92 ± 0.641	4.47 ± 0.516	< 0.001*	0.147	0.027	0.004
Visual Cues	3.15 ± 0.899	3.92 ± 0.669	4.40 ± 0.507	< 0.001*	0.031	0.054	< 0.001

Data are presented as mean scores on a 5-point Likert scale, with higher scores indicating greater perceived confidence

* Indicates statistical significance at p < 0.05 before Bonferroni correction. Following Bonferroni correction, significance was established at p ≤ 0.002

IFRAH-Neuro-Integrative Functional Rehabilitation And Habilitation

Qualitative findings helped contextualize the quantitative survey results by illustrating how participants adapted evidence-based rehabilitation concepts within resource-constrained clinical environments. Although mirror training and orthotic assessment did not demonstrate a significant change, during focus group interviews, participants noted creative adaptations of the techniques when they did not have access to equipment. Additionally, many participants disseminated their newly acquired knowledge through course promotion and collaborative problem-solving with other rehabilitation professionals.

Focus group interviews with seven participants occurred six months following the completion of the course. Four themes were discovered; (1) Challenges in Rehabilitation Perception (2) Need for enhanced training in fine motor skills, (3) Resourceful adaptation of techniques for context, and (4) Importance of a learning community. Two themes were related to the challenges in providing rehabilitation in Myanmar. While two themes emphasized the perseverance of the physiotherapists.

Theme 1: Challenges in rehabilitation perception

Participants emphasized the need for additional education, enhanced referral practices, and greater organizational or governmental support to improve the effectiveness of rehabilitation efforts. They noted a prevalent belief, held by both healthcare providers and the community that rehabilitation is unnecessary or ineffective. Beliefs such as these led to a lack of referrals and motivation for seeking or adhering to rehabilitation services.

They [referral sources] need more education. Also, we need early referral and support available from the organization or the government. Because sometimes we want to do a lot, yet we can only give education one-to-one unless the organization schedules or plans for a group of people. Mostly we try our best to explain how important rehabilitation is, but it takes time because of the limited belief.

In addition to the lack of referrals, participants noted that patients had minimal understanding of functional gains that could be made in rehabilitation following a stroke.

See if they have a stroke, most people in our country believe that you don’t need to go out. Just stay at home. No need to go anywhere. Just lie on the bed. Things like that. They don’t understand if you have a stroke, then you can go for rehabilitation and can get better.

Additional challenges for participation in rehabilitation included lack of family support and limited focus on fine motor function, which contribute to high dropout rates from rehabilitation programs. There is a general perception that broader functional improvements, such as walking and community participation, are sufficient, often overshadowing the importance of fine motor skills.

Mostly they quit from rehabilitation and that is mainly because there are financial difficulties or other challenges. Also, their family is not willing to support the patient. There is the opinion that hand-function is, from the caregivers’ side, not really important. The patient can walk and can visit around. The participation in the community is improved a lot already.

Theme 2: Need for enhanced training in fine motor skills

Participants noted a critical gap in rehabilitation training for physiotherapists in Myanmar, specifically regarding fine motor skills. There is a challenge of addressing fine motor control due to the lack of specialized occupational therapists, forcing physiotherapists to manage both gross and fine motor skills despite limited training. This may contribute to the community belief that gains in gross motor skill are the primary expectation for improvement following a stroke.

For me, my challenge and difficulty for stroke patients is fine motor skill training. Gait training, we can do, and we can assist the patient to be independent. But to use the hand and improve hand function is still challenging…. In Myanmar, we don’t have occupational therapists. That’s why physiotherapists need to take care of fine motor skills also.

Theme 3: Resourceful adaptation of techniques for context

Participants discussed the innovative adaptation of rehabilitation techniques in remote and resource-constrained environments. Despite challenges such as the lack of specific equipment, therapists creatively repurposed available resources and common household objects to apply concepts like mirror therapy. They use alternatives such as sand, shadows, and makeshift mirrors (e.g., flashlights and sheets) to achieve therapeutic goals. Understanding the theory behind the technique allowed the therapists to develop alternatives with similar results. The overarching theme highlights the importance of flexibility and ingenuity in delivering effective rehabilitation with limited resources.

It’s really applicable, especially the mirror therapy. The settings I am working is very, very remote places. It is very difficult to get all the resources, like mirrors. So I use the sand and their [the patient’s] shadow to create a mirror effect. So instead of looking at the mirror, the client sees his own shadow, and then they will walk on the ground. It is really very useful and I can see the progress, the very, very fast progress.

Another participant illustrated the creative application of techniques taught within the program within the context of the country.

We cannot directly apply the technique that we learn from the program, but we can use it as an idea and modify it based on the context…You need to think of an alternative way based on the idea that we have learned from that training program. All these therapists joining, they are very creative. They were used to using whatever was in the environment.

This resourcefulness extends to using elastic bandages and bands to simulate orthotics, demonstrating the therapists’ ability to modify resources to fit different contexts and patient needs.

For the foot drop patient especially, so they [the therapists] used elastic bandage or whatever was available at the center. They use the framework, the theory, and they implement it, then modify it differently.

Not only did participants note the use of available resources to support therapy, they discussed being able to apply the techniques to other populations. One therapist, who mainly treats pediatric patients, made the following comment.

Using bandage to prevent a foot drop, but maybe it’s not a foot drop, but I still can use it for another purpose during the gait training for the kids. So actually, I feel like everything is thinking about theory and why. I use the idea, the technique and apply it to all populations.

Theme 4: Importance of a learning community

The participants engaged in the online rehabilitation community platform to share ideas and post discussions. They highlighted the significant role of community support and personal motivation in advancing their professional development. Sharing progress through videos and social media not only fostered a sense of accomplishment but also encouraged others to engage in learning and improvement.

We shared a gait training video on the rehab community. That was the initial evaluation. So after treatment, we took another video of the current condition. Then we can see the improvement. Also, the patient was himself very happy to see his improvement. Then he also encouraged others, his friend who recently had a stroke.

The active sharing of course completions and certificates on Facebook added to the collective motivation, though maintaining this momentum can be challenging amidst professional and personal demands.

How can I say, I posted my course completion, the certificate, in my Facebook story and some of my colleagues and friends, physiotherapists, they are asking me if I still continue [completing courses] and many ask how to join on learning platform.

Another participant noted seeing the course certificate being posted motivated them to study more.

During that period [the formal training program] we really studied a lot, but after that, lesser…. Everybody is sharing on Facebook, so my motivation is to study more. Even some of them, they did not join the clinical skills training. But when they see us studying, then they all feel like I want to study. I need to study. Everyone is sharing all the certificates.

The participants also discussed the struggle to remain committed to professional development and lifelong learning.

We need to have that kind of motivation to constant learning. Because sometimes, especially when you are working full-time and also a lot of those factors affecting your mental health, especially, you know, in Myanmar. They feel very drained. Especially for those without electricity. So, sometimes they are lost, they just get very tired.

Participants expressed appreciation for the supportive and familial atmosphere fostered through both online and in-person training, which enhanced their commitment to continuous learning. Many of the participants worked in rural areas and did not have colleagues to support their practice.

Only when I join Physiopedia that I start communicating with them [other physiotherapists in the country], that I get to know them. Some of them I never met the outside, but I feel very familiar. We discuss things together during the in-person training and during [online] discussions, that is really very good experience.

The group continued to meet online once a month to present case studies and discuss the application of the evidence even after the training. The clinical skills training experience gave them the confidence to seek out local topic experts, whom they now invite to present and support the group of rehabilitation professionals that completed the training. This underscored the importance of a supportive network in sustaining professional growth and overcoming challenges.

Discussion

This study assessed the effectiveness of a contextually tailored stroke rehabilitation training program for rehabilitation professionals in Myanmar by examining changes in perceived knowledge, skills, and clinical implementation, while exploring barriers and facilitators influencing application in practice. Quantitative findings demonstrated improvements in participants’ self-reported confidence and knowledge of evidence-based stroke rehabilitation techniques, particularly interventions requiring minimal equipment. Qualitative findings expanded on these results by illustrating how participants adapted learned concepts to resource-constrained environments, shared knowledge with peers, and navigated challenges related to rehabilitation perceptions, workforce limitations, and infrastructure instability. Collectively, these findings suggest that continuing professional development programs that emphasizing adaptability, peer learning, and resource-conscious implementation may support the application of evidence-based rehabilitation practices in complex health care environments. Rather than focusing on direct replication of resource-intensive rehabilitation models commonly used in HICs, the findings highlight the importance of implementation approaches that prioritize contextual adaptation, flexible application of evidence-based principles, and peer-supported problem-solving within constrained clinical environments.

Similar to other studies on the challenges of stroke rehabilitation in LMICs, participants identified low health literacy among caregivers and a limited understanding of rehabilitation among both families and referring healthcare providers as barriers to rehabilitation participation and continuity of care [2, 22]. The participants in this study reported that low expectations for recovery following stroke reduced motivation to pursue rehabilitation. In contrast, previous studies have reported that unrealistically high expectations of complete recovery may also contribute to discontinuation of therapy when expected improvements are not achieved [2]. Together, these findings suggest that both unrealistically high and unduly limited expectations for recovery may negatively influence rehabilitation adherence. The participants also noted that referring healthcare providers had a limited understanding of the benefits of rehabilitation for functional recovery following a stroke, resulting in delayed or absent referrals to rehabilitation services. This barrier has been observed in other LMICs [22]. Limited referral pathways partly reflect the absence of rehabilitation within standard stroke care protocols and the limited availability of providers with specialized rehabilitation training [22]. Recently, the third Stroke Recovery and Rehabilitation Roundtable developed consensus recommendations advocating for the evaluation of balance and mobility following stroke using assessments that do not require specialized equipment and may therefore be feasible within LMIC stroke care systems [14]. These findings collectively highlight the importance of integrating accessible rehabilitation assessments and education into broader stroke care pathways in resource-constrained settings.

The importance of rehabilitation education in Myanmar is further amplified by the country’s limited access to specialized stroke services. Prior to 2021, stroke care in Myanmar was primarily delivered by general physicians in urban areas and general practitioners or health assistants in rural regions, with limited access to neurologists and specialized rehabilitation services [15]. Although healthcare provider surveys indicated awareness of risk factors such as hypertension and the value of early physiotherapy, practice patterns often deviated from evidence-based recommendations [15]. Limited access to thrombolysis and the absence of resources for thrombectomy further underscore the importance of post-stroke rehabilitation in the country [11, 12]. Within this context, participants reported applying evidence-based examination and treatment approaches learned during the program despite significant workforce and infrastructure limitations. The survey findings demonstrating increased confidence in low-technology rehabilitation approaches aligned with focus group discussions describing creative adaptation of interventions using locally available resources. These integrated findings suggest that rehabilitation education programs in LMICs may benefit from emphasizing transferable clinical reasoning skills and adaptable treatment principles rather than reliance on resource-intensive technologies commonly utilized in HIC rehabilitation settings.

Workforce limitations also shaped how participants applied rehabilitation concepts in practice. The World Stroke Organization recommends that rehabilitation following a stroke should include physiotherapy, occupational therapy, and speech and language therapy [16]. However, because physiotherapists constitute the principal rehabilitation workforce in Myanmar, they are frequently tasked with addressing patient needs that extend beyond their traditional scope of practice, including activities typically delivered by occupational therapists in HIC settings [23]. This challenge was reflected in the qualitative theme identifying the need for additional training in fine motor rehabilitation following stroke. Current clinical practice guidelines support interventions such as mirror therapy, ankle-foot orthoses, and functional electrical stimulation to improve upper extremity function and mobility following stroke [17, 19, 20]. However, many recommendations developed in HICs presume access to equipment, technology, and rehabilitation intensity levels that may not be feasible in LMIC environments [17, 18]. Recent reviews have additionally noted that stroke rehabilitation clinical practice guidelines developed within LMICs remain limited in number and methodological quality, with many relying heavily on adaptation from HIC recommendations [24]. Participants in this study demonstrated adaptation of rehabilitation theory and evidence-based principles to local clinical realities while maintaining intended therapeutic goals. These findings suggest that rehabilitation education in resource-constrained settings may benefit from emphasizing contextual adaptation of evidence-based principles rather than strict replication of resource-intensive protocols developed in HICs. These findings also align with broader discussions regarding task-sharing and workforce adaptation within LMIC rehabilitation systems, where shortages of specialized rehabilitation professionals frequently require physiotherapists to assume expanded clinical responsibilities [2, 22]. In this context, continuing professional development programs may play an important role in supporting rehabilitation providers as they adapt evidence-based rehabilitation approaches to meet diverse patient needs within constrained healthcare systems.

In addition to contextualizing clinical practice guidelines, rehabilitation effectiveness can be objectively assessed using standardized outcome measures, which are widely endorsed internationally [28]. Both the Intercollegiate Stroke Working Party and the World Health Organization (WHO) have emphasized the importance of measuring functional outcomes to monitor rehabilitation progress and inform clinical decision making [25, 26]. Similarly, the WHO has developed assessment tools that align with the International Classification of Function, Disability and Health assisting healthcare professionals in evaluating post-stroke outcomes [26]. However, clinicians often encounter difficulties selecting appropriate assessments from the large number of available outcome measures, especially since not all possess strong psychometric properties [27]. The selection of outcome measures should be guided by evidence-based practice, psychometric quality, and relevance to the clinical environment. Participants in this study reported increased use of outcome measures following the training program, aligning with the survey findings that demonstrated greater confidence in evidence-based stroke rehabilitation approaches. Incorporating standardized assessments within LMIC rehabilitation settings may enhance the quality of care by providing objective measures of patient progress and treatment effectiveness, while also supporting advocacy for rehabilitation among healthcare providers and referral sources. However, Myanmar currently lacks systems for the efficient collection and analysis of rehabilitation data [28]. Consequently, while outcome measures may support local clinical decision-making and advocacy efforts, the absence of electronic health records and national rehabilitation databases continues to limit broader rehabilitation research and the contextualization of clinical practice guidelines in the country.

Beyond acquisition of clinical knowledge and skills, participants described the importance of ongoing peer interaction and professional networking following completion of the training program. Healthcare professionals often display traits of lifelong learners; however, once they transition from formal educational environments, they must independently identify and address gaps in their knowledge and skills [29]. This iterative process requires self-motivation and the integration of lifelong learning principles into clinical practice. Social media and online networking platforms may enhance this process by facilitating continuous interaction, collaboration, and informal learning among healthcareprofessionals [30]. In the present study, participants used online meetings and social media platforms to encourage accountability, share resources, discuss patient cases, and provide peer mentorship following completion of the training program. These interactions were particularly valuable, as participants reported minimal professional networking opportunities with other physiotherapists prior to the training. Qualitative findings suggested that the online learning environment contributed to the development of a supportive virtual community of practice, which facilitated collaborative problem-solving and adaptation of rehabilitation strategies to local clinical realities. Similar findings have been reported in a recent study of physical therapy residency programs in the United States, which identified intentional development of communities of practice as important for fostering adaptive learning and accelerating professional growth among novice clinicians [31]. These findings suggest that ongoing mentorship and peer-learning networks may represent important components of continuing professional development programs in resource-constrained rehabilitation settings.

One limitation of this study was the small sample of convenience drawn from a single country, which limits the generalizability of the results and introduces potential selection bias. Participants who volunteered may have been more motivated to learn and implement new techniques than the broader population of physiotherapists in Myanmar. Additionally, our outcomes were primarily based on self-reported measures of knowledge and skills rather than objective assessments of clinical performance or patient outcomes. While self-reported measures offer valuable insights into participants’ perceptions of their abilities, they may be subject to social desirability bias or the overestimation of competence. Furthermore, although focus group interviews were conducted with the assistance of a healthcare interpreter, some nuances of the participants’ experiences might have been lost in translation, potentially affecting the depth and accuracy of qualitative findings. Finally, it is crucial to consider the broader health system in Myanmar. Since the political events of 2021, reliable information on healthcare access and rehabilitation services has been limited, with reports indicating disruptions to health service delivery and infrastructure [32–35]. These circumstances likely impact the availability and sustainability of stroke rehabilitation, posing additional challenges in implementing evidence-based practices.

Conclusion

The use of a training program combining online training, mentoring, and in-person training supported participants’ self-reported application of evidence-based stroke rehabilitation approaches in Myanmar. Although the small sample size limits the generalizability of the findings, it demonstrated how rehabilitation professionals adapted evidence-based concepts and low-technology interventions within a resource-constrained environment. These findings suggest that contextualized continuing professional development programs incorporating peer learning, mentorship, and adaptable implementation strategies may be valuable in low-resource settings affected by workforce and infrastructure limitations. Further research is needed to evaluate long-term implementation and patient-level outcomes associated with these educational approaches.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

IFRAH

Neuro-Integrative Functional Rehabilitation And Habilitation

HICs

High Income Countries

LMICs

Low- and Middle- Income Countries

MT-GLASS

Mechanical Thrombectomy Global Access for Stroke Study

WHO

World Health Organization

Author contributions

SC Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Writing-original draft, Visualization. ML and HM Conceptualization, led the design and implementation of the training program, Writing-review and editing. RL Conceptualization, Funding Acquisition, Coordination of learning resources, Writing-review and editing. DM Content expert, Writing-review and editing. AB Conceptualization, Funding, Approval of Final Manuscript.

Funding

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

Data availability

All data generated or analysed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

This study (IRB No. 21399) was reviewed by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board and classified as exempt. All procedures involving human participants followed institutional and national ethical standards and adhered to the Declaration of Helsinki and its later amendments. Informed consent was obtained from all participants, and confidentiality was maintained throughout data collection, analysis, and reporting.

Consent for publication

NA.

Competing interests

The authors declare no competing interests.