Abstract
BACKGROUND:
Despite earlier recognition of the importance of motor learning principles in neurorehabilitation, research suggests that the motor learning principle is not being entirely utilized in neurorehabilitation. Implementation of motor learning principles has been associated with functional recovery and patient satisfaction.
OBJECTIVE:
To examine implementation of motor learning principles in neurorehabilitation among Saudi physical therapists including self-efficacy, current practice, attitude and barriers.
METHODS:
A cross-sectional survey of physical therapists managing patients with neurological conditions was conducted (n = 345). The survey questionnaire contained items to evaluate self-efficacy, current practice, attitude and barriers toward implementing motor learning principles in neurorehabilitation.
RESULTS:
The data from the respondents indicated that they had moderate self-efficacy to implement motor learning in neurorehabilitation. Only 30.2% of respondents implement motor learning in their practice to a high degree and some respondents were unaware of the concepts of motor learning. The most reported perceived barriers to motor learning implementation in neurorehabilitation were at the level of the physical therapist (lack of knowledge) and the organization (lack of time).
CONCLUSION:
Implementation of motor learning principles among Saudi physical therapists managing patients with neurological conditions was moderate. Self-efficacy, positive attitudes, academic training and organizational support are potential strategies to enhance implementation.
Introduction
Neurological disorders are the leading cause of disability worldwide. The Global Burden of Diseases, Injuries and Risk Factors (GBD) Study reported that neurological disorders caused 250.7 million disability-adjusted life years (DALYs; the sum of years of life lost and years lived with disability) in 2015, an increase of 7.4 percent from 1990 (Feigin, 2019). The burden of neurological disorders is rapidly being recognized as a global public health concern, and this burden is expected to rise over the next few decades (Feigin, 2020).
In this context, there is a substantial and increasing need for rehabilitation services worldwide (Jesus et al., 2019). A recent systematic analysis reported that rehabilitation services can prevent a larger proportion of the global burden of disability (Cieza et al., 2020). Neurorehabilitation services should be the cornerstone of the management and recovery of function following a neurological injury. Neurorehabilitation aims to promote functional outcomes and quality of life in patients by reinforcing their independence and participation (Katz & Dwyer, 2021). Barnes (2003, p. iv3) defines neurorehabilitation as “a process of education of the disabled person with the ultimate aim of assisting that individual to cope with family, friends, work, and leisure as independently as possible”.
Neurorehabilitation based on established principles of motor learning and neural plasticity may be one of the most promising approaches that provides optimal functional outcomes for neurological recovery (Levin & Demers, 2021). Motor learning is a core concept to integrate into physical therapy practice in order to improve patient outcomes (Kafri & Atun-Einy, 2019). It is defined as a set of internal processes associated with practice and experience that result in relatively permanent changes in motor skill execution (Schmidt et al., 2018).
Physical therapists are essential interdisciplinary team members who play an important role in maximizing recovery for people with neurological conditions and have a strong potential to increase the effectiveness of neurorehabilitation interventions, supporting the importance of examining their implementation of motor learning. Despite the promising findings related to the motor learning principle in neurorehabilitation, the associated principles are not being applied to rehabilitation practice as they should be. Previous studies showed that physical therapists have a high degree of variability in how they apply motor learning (Atun-Einy & Kafri, 2019; Atun-Einy & Kafri, 2021; Johnson et al., 2023).
These variations in practice may be due (in part) to the complexity of the behavioral perspective involved in implementing motor learning interventions such as self-efficacy and attitude as well as the many different potential determinants of such behaviors, including factors related to organizational context, patient and professional competence (Atun-Einy & Kafri, 2019; Atun-Einy & Kafri, 2021; Winstein et al., 2014).
Examining the implementation of the motor learning principle in neurorehabilitation among physical therapists and the factors that influence their behaviors is a precursor step for the development of effective strategies to enhance physical therapists’ implementation of motor learning principles in neurorehabilitation. The present study aims to examine the implementation of motor learning principles in neurorehabilitation among Saudi physical therapists including self-efficacy, current practice, attitude and barriers.
Methods
Design and participants
This was a cross-sectional questionnaire study. We recruited Saudi physical therapists, who were involved in providing healthcare to people with neurological conditions. Students and intern physical therapists were excluded. This study was conducted according to the guidelines of the Declaration of Helsinki and approved by the College of Medicine Institutional Review Board (IRB) at King Saud University Medical City (IRB No. E-21-6351). All participants signed a consent form prior to participation.
According to the Saudi Commission for Health Specialties, the number of Saudi physical therapists was estimated to be 5500 at the time of the survey (World Physiotherapy, 2021). The sample size needed for this study was estimated using Daniel’s formula (Daniel & Cross, 2018). An online sample size calculator (https://www.calculator.net/sample-size-calculator.html) was used to calculate the sample size at a 90% confidence interval and a 5% margin of error to be 260 physical therapists. To account for potential dropouts, we invited more than the sample size needed for this study.
Survey
A self-administered, web-based, cross-sectional questionnaire was used for the purposes of this study. The content of the questionnaire was adapted from a prior survey (Atun-Einy & Kafri, 2019) and further developed to suit this study. The cross-sectional questionnaire consisted of three sections and was administered through SurveyMonkey. The first section included questions related to sociodemographic and professional characteristics, including gender, age, education, area of practice, and practice experience. Also, questions related to the inclusion of motor learning in their educational background. The second section included questions regarding self-efficacy, current practice, and attitudes toward implementing motor learning principles in neurorehabilitation. The third section included six statements about barriers to implementing motor learning principles in neurorehabilitation. These statements involve lack of knowledge, working situations (working habit, overload at work, lack of time), environmental factors (e.g., limited space, crowded and noisy treatment area), health care-related barriers (e.g., safety demands, limited number of sessions), patient characteristics (e.g., lack of motivation, age), and the complexity of motor learning-based intervention.
Self-efficacy of implementing motor learning in neurorehabilitation was assessed with 12 items on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Self-reported current practice of implementing motor learning in neurorehabilitation was assessed with 12 items on a 5-point Likert scale ranging from 1 (very little) to 5 (very much) or 0 if the respondents chose (unaware of this element). The attitude toward implementing motor learning in the workplace was assessed with four items on a 5-point Likert scale ranging from 1 (very little) to 5 (very much). The median scores were calculated for each item assessed in the questionnaire. The average of all item responses is calculated, with scores below 3 (the neutral point) considered low and above 3 considered high (Vaz et al., 2021).
Data collection
Prior to data collection, a pilot survey was conducted among a sample of 10 expert Saudi physical therapists. The survey took 10–15 minutes to complete. Respondent feedback was received in two weeks, based on which some changes were made related to consistency of style, formatting, and clarity of response options. After reformatting, the electronic link to the survey was disseminated to the participating physical therapists via the email lists of the Saudi Physical Therapy Association (SPTA) and Saudi physical therapists employed by the Ministry of Health (MOH). In addition, posts on social media sites and invitations with links to the survey were shared by physical therapists.
Statistical analysis
All statistical analyses were conducted using SPSS® version 25 (IBM, Armonk, NY, USA). Descriptive statistics were computed to describe the demographic characteristics of the respondents. Frequency counts and percentages were used to summarize survey responses related to self-efficacy, current practice, attitude, and barriers toward the implementation of motor learning principles in neurorehabilitation. For the scale items, we pooled the ‘strongly agree’ and ‘agree’ categories to form an ‘agree’ category and ‘disagree’ and ‘strongly disagree’ categories to form a ‘disagree’ category. We pooled ‘very much’ and ‘a lot’ categories to form ‘very much’ category and ‘very little’ and ‘a small degree’ categories to form the ‘very little’ category. Given that the data from the survey were not normally distributed, as confirmed with the Kolmogorov test, they were described using medians and the interquartile range (IQR). Correlation tests were done between the aggregated outcome measures using the Spearman’s rank correlation coefficient (rs). Associations between the average outcomes (self-efficacy, current practice, attitude) and sociodemographic and professional characteristics of respondents were explored using non-parametric tests, that is, the Spearman’s rank correlation coefficient (rs), the Mann-Whitney U test (U), and the Kruskal–Wallis test (H), where appropriate. The level of statistical significance was set at p < 0.05.
Results
Characteristics of the respondents
The characteristics of the respondents are shown in Table 1. The mean age of the participants was 31.2 years (SD = 6.6). The majority of respondents, 57.4% (n = 198) were female; and 73.2% (n = 252) had obtained a bachelor’s degree as their highest degree. Almost half of participants 54.2% (n = 187) had 1–5 years of practice experience. Regarding the inclusion of motor learning in their educational background, 65.8% (n = 227) of physical therapists indicated that they had lectures about motor learning in neuro classes during their undergraduate study. However, 58.8% (n = 203) of physical therapists reported not participating in post-graduate courses focusing specifically on motor learning.
Sociodemographic and professional characteristics of respondents (n = 345)
Sociodemographic and professional characteristics of respondents (n = 345)
Notes: *Age presented as mean and standard deviation. Abbreviation: PT, physical therapy; ML, Motor learning.
Table 2 depicts the self-efficacy of physical therapists in implementing the principles of motor learning in neurorehabilitation. Only 46.9% of the 273 respondents said they ‘agree’ that they are confident in using motor learning to treat patients with neurologic conditions. More than half of the respondents (62.5%) agree that they need a lot of motor learning training to be able to use this approach for neuro patients; whereas 40.7% of survey respondents ‘agree’ that they have no difficulty implementing the motor learning principle in treatments for patients with neurologic conditions.
Self-efficacy in implementing motor learning in neurorehabilitation among physical therapists (n = 273)
Self-efficacy in implementing motor learning in neurorehabilitation among physical therapists (n = 273)
Abbreviation: IQR, Interquartile range—75th percentile –25th percentile; ML, Motor learning; MLP, Motor learning principle.
Of the 235 respondents, 31.1% reported they implement motor learning in their practice ‘very much’. Only 28.5% of the respondents stated that giving instruction involved an external or internal focus of attention, and 33.1% modulate environmental factors and motor demands to generate challenge during practice. Almost 14.0% of physical therapists were unaware of whether the feedback would be based on ‘’knowledge of result” or ‘’knowledge of performance”. The highest number of respondents (47.0 %) reported structure in the number of repetitions within a practice (Table 3).
Self-reported current practice of implementing motor learning in neurorehabilitation among physical therapists (n = 235)
Self-reported current practice of implementing motor learning in neurorehabilitation among physical therapists (n = 235)
Abbreviation: IQR, Interquartile range—75th percentile –25th percentile; ML, Motor learning; MLP, Motor learning principle.
Only 29.0 % of the 221 respondents were given enough time to treat patients using the motor learning principle, and only 15.0% largely agreed that physical therapists in their field use the motor learning principle very much (Table 4).
Attitudes towards implementing motor learning in the workplace (n = 221)
Attitudes towards implementing motor learning in the workplace (n = 221)
Abbreviation: IQR; Interquartile range—75th percentile –25th percentile; ML, Motor learning; MLP, Motor learning principle.
Self-efficacy, current practice, and attitude of physical therapists towards implementing motor learning in neurorehabilitation were positively correlated (p < 0.05) (Table 5).
Correlation between self-efficacy, current practice and attitude towards implementing motor leaning in neurorehabilitation
Correlation between self-efficacy, current practice and attitude towards implementing motor leaning in neurorehabilitation
Abbreviation: IQR, Interquartile range —75th percentile –25th percentile; rs, Spearman’s rank correlation coefficient. *p < 0.05.
Self-efficacy scores were significantly higher (U = 4.7; p < 0.0001) among participants who participated in post-graduate courses that focused specifically on motor learning than those of other participants. No other statistically significant differences were observed between respondents’ sociodemographic and professional characteristics and their total self-efficacy, self-reported current practice and attitude scale scores towards implementing motor leaning in neurorehabilitation (Table 6).
Associations between sociodemographic/professional characteristics and self-efficacy, current practice and attitude
Associations between sociodemographic/professional characteristics and self-efficacy, current practice and attitude
Note: aSpearman’s rank correlation coefficient, bMann-Whitney test, cKruskal-Wallis test. Abbreviation: ML, motor learning; IQR, interquartile range —75th percentile –25th percentile; H, Kruskal-Wallis test; U, Mann-Whitney test; r s , Spearman’s rank correlation coefficient. *p < 0.05.
A total of 219 physical therapists answered the barriers section of the questionnaire. The most common reported perceived barriers to motor learning implementation in neurorehabilitation were at the level of the physical therapist (lack of knowledge) and the organization (lack of time), at 45.8% and 35.9%, respectively (Fig. 1).
Barriers to implementing motor learning principles in neurorehabilitation among physical therapists (n = 219). Note: Participants were able to choose more than one answer and up to six answers.
Following a neurological injury, motor learning principles offer physical therapists the framework and guidance needed to maximize functional recovery. Implementation of motor learning principles leads to permanent improvement due to its ability to enhance neuroplasticity after injury. However, research suggests that the motor learning principle is not being entirely utilized in neurorehabilitation in Saudi Arabia. To our knowledge, this is the first study investigating physical therapists’ implementation of motor learning principles in neurorehabilitation.
One of the objectives of this study was to examine physical therapists’ self-efficacy in implementing motor learning principles into their clinical practice within a neurorehabilitation setting. Self-efficacy beliefs, defined as judgments of capacity to plan and execute certain performances (Bandura, 1977), are regarded as the key determinant of decisions to engage in or avoid specific activities or settings. Self-efficacy has been implicated in long-term behavioral engagement as a motivational factor. Self-efficacy could mediate clinical behavior toward implementing knowledge and theories within practice (Godin et al., 2008). The data from the respondents indicated that they had moderate self-efficacy to implement motor learning in their clinical practice in neurorehabilitation. This finding seems to be in line with previous research on physical therapists’ in Israel (Atun-Einy & Kafri, 2019).
Only a third of therapists in our study agreed they were confident in knowledge-based assessments related to motor learning principles, such as distinguishing between two concepts or the extent to which they would be confident applying treatment based on the principle of motor learning to patients with neurological conditions. A recent study found physical therapists frequently use internal focus of attention and nonspecific feedback (Johnson et al., 2023). Also, a previous study reported that it might be challenging for physical therapists to choose the most appropriate motor learning approach for their patients (Levac et al., 2016).
Despite earlier recognition of the importance of motor learning principles in neurorehabilitation (Franz et al., 1915), only 30.2% of respondents implement motor learning in their practice to a high degree, and some respondents were unaware of the concepts of implementing motor learning. Approximately, half of the respondents, agree that they need a lot of motor learning training to be able to use this approach for neuro patients. Low self-efficacy and lack of motor learning implementation may be explained by educational background, different training backgrounds, and the complexity of motor learning knowledge (Bramley et al., 2018; Vaz et al., 2021; Levac et al., 2016). A previous study that studied the impact of learning opportunities on the self-efficacy of physical therapists concluded that through the learning opportunities, physical therapists had increased self-efficacy and could communicate better with their patients (Kleynen et al., 2015). A recent study reported that delivering motor learning knowledge through an active learning style, e.g., labs, can enhance the self-efficacy of motor learning concepts within objective evaluation (Vaz et al., 2021). Atun-Einy and Kafri, 2019 reported that the inclusion of motor learning in postgraduate studies facilitates its implementation in the clinical practice of physical therapists. In line with these studies, physical therapists in our study who participated in post-graduate courses that focused specifically on motor learning had significantly higher self-efficacy in implementing motor learning in neurorehabilitation than those of other participants. However, translating knowledge in order to implement motor learning in current practice is still limited (Kafri et al., 2023).
We measured the attitude of physical therapists towards implementing motor learning on an individual level and on a group level within interdisciplinary teams, such as ‘I can consult with my peers at my workplace about giving motor learning-based treatment for neuro patients’ and ‘To what extent do physical therapists in your field use the motor learning principle’. Attitude towards implementing motor learning in the workplace is a construct closely linked to self-efficacy beliefs, and our findings show that attitudes help to explain the implementation of motor learning principles. In the current study, self-efficacy, current practice, and attitude towards implementing motor learning within neurorehabilitation are interrelated factors. This correlation indicates that enhancing the confidence of physical therapists and their attitude may facilitate the implementation of motor learning principles in neurorehabilitation. These findings are in line with a recent study reporting that knowledge increases can enhance self-efficacy and attitudes toward implementing motor learning within physical therapists practices (Kafri et al., 2023).
Consistent with previous studies, lack of knowledge followed by working situations, e.g., lack of time and overload at the workplace, were the most reported barriers to implementing motor learning in neurorehabilitation among Saudi physical therapists (Atun-Einy & Kafri, 2019; Jette et al., 2003; Salbach et al., 2007). This study highlights the need for educational activities and postgraduate training programs targeting competence in neurorehabilitation in the clinical practice environment, which may enhance self-efficacy and promote motor learning implementation among Saudi physical therapists. However, little is known about the integration of motor learning principles in the curricula of physical therapy programs among universities in Saudi Arabia or in clinical internships and residency programs for physical therapists, and the extent to which this is enforced is also unknown.
Some potential limitations of this study should be acknowledged. First, each section of the survey has a different response rate, which could affect the validity of our results. Second, our cross-sectional study did not allow casual inferences to be drawn. Lastly, our sample comprised only physical therapists in Saudi Arabia, so the findings cannot be generalized to all physical therapists.
Conclusion
Implementation of motor learning principles among Saudi physical therapists managing patients with neurological conditions was moderate. Our findings support the contribution of postgraduate education focusing specifically on motor learning to enhance self-efficacy in the implementation of motor learning in neurorehabilitation. Self-efficacy, positive attitudes, academic training, and organizational support are potential strategies to enhance implementation. The findings of this study demonstrate the necessity for future studies to examine strategies to improve implementation outcomes that target physical therapists and organizations.
Conflict of interest
The authors have no competing interests to declare.
Funding
The authors report no funding.
Footnotes
Acknowledgments
This work was supported by the Research Center of the Female Scientific and Medical Colleges, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.