Various therapeutic approaches exist for the rehabilitation of stroke patients such as Proprioceptive Neuromuscular Facilitation (PNF), Brunnstrom Approach, Motor Re-learning Programme (MRL), and Bobath (also called Neuro Developmental Treatment (NDT). The purpose of the study was to highlight the current clinical practice of Saudi physiotherapists in stroke rehabilitation treatment. Though, online survey was used to collect the data but the response rate was 68.64%.
The majority (51.8%) of participants in this study had less than 5 years’ experience in treating patients with stroke rehabilitation. That has highlighted the fact that there are limited or zero physiotherapy programmes linked with stroke in different regions of Saudi Arabia. Nearly all participants in this survey have received training in both approaches: Brunnstrom/ PNF and Bobath/NDT during their basic training education. Moreover, both methods were used widely in their real practice for stroke rehabilitation (Brunnstrom/ PNF 77.66% and Bobath/NDT 63.45% respectively). However, it is necessary to note that both approaches lack the robust evidence in order to support their effectiveness.
Previous studies showed that Bobath theory being widely accepted in physiotherapy, there is no validated evidence of its superiority is observed[14,16]. Furthermore, other findings revealed that there is no statistical significant differences, in favour of the Bobath group, were found between stroke patients that have been treated according to the Bobath method verses stroke patients that have been treated according to alternative approaches such as traditional functional treatment, CIMT, electrotherapy, or motor relearning programme.
The result of current study can be compared to previous conducted researches that have investigated the practice of physiotherapy in stroke rehabilitation in diverse countries including the United States, Sweden, the United Kingdom, and Australia. Based on the survey results, around 94% of Saudi physiotherapists agreed to aim and re-educate normal movement for stroke rehabilitation and facilitate adaption to function in their current practice with stroke patients. Findings suggested that receiving the highest percentages on both aims may represents different approaches. This may indicate that using one method alone in stroke rehabilitation is not effective but using different approaches are required to be used to treat stroke patients based on patients’ case history.
Findings showed that around 87% of participants have suggested that tone should be normalized when facilitating movement. This response is closely linked to Bobath/NDT approach, which pointed out towards facilitating encouragement of normal movement patterns while inhibiting tone. However, diverse literature has concluded on the comparisons of Bobath or Burnnstrom/PNF methods with other approaches that do not demonstrate any validated evidence of its superiority over the other approaches, in stroke rehabilitation.
One of the core concepts linked with the contribution of physiotherapy in stroke rehabilitation is constraint induced therapy movement therapy (CIMT). However, only 16 (8.12%) participants reported that they have been taught in their basic training and 50(25.38%) participants used CIMT in their real clinical practice. The characteristic of intensive, repetitive, and task–specific training of CIMT might explain the existing variations between physiotherapists among their learning of CIMT in the basic education and using of CIMT in the real clinical practice. Moreover, since the use of such approaches and other strategies (such as functional electrical stimulation, bilateral arm training, mirror therapy and biofeedback) were not a common practice in stroke rehabilitation in Saudi Arabia, thus they have faced many issues linked with therapist factors (such as knowledge, skills and beliefs about the research ) and organisational factors (such as culture, courses and resources) which needs more investigations to close this gap between evidence and clinical practice. This may explain the low percentage of these strategies in real practice.
The majority of participants (66%) suggested that performing activities should be delayed if these activities reinforcing abnormal movement patterns. However, there is no evidence that has shown that delaying in some patterns will affect negatively or abnormal tone or movement. Nearly half of participants (49%) believed that single plane movement can be useful in improving the function, whereas rest of the participants disagreed or uncertain about it.
This paper is considered as the first and foremost study that has investigated the current practice of Saudi physiotherapists in stroke rehabilitation. However, the research questionnaire lacked consideration of influencing factors while implementation of evidence in stroke rehabilitation in real practice such as context of practice and service delivery. Furthermore, future studies need to engage therapists to test any intervention practice in stroke rehabilitation against best practice, rather than usual care which is not considered as an evidence-based practice.