Stroke Disability and Physiotherapy Interventions: A Quantitative Evaluation of Physiotherapy Treatment Approaches' in Zambia

IJDS 2020; Vol. 7 No. 1, May 2020, pp.
92-100 92
ISSN: 2355 – 2158 e-ISSN: 2654-4148
DOI: dx.doi.org/10.21776/ub.ijds.2019.007.01.10
Cite this as:
Muatle Mpemba, Hstings Kachingwe Shula, Brian Chanda Chiluba. Stroke Disability and Physiotherapy
Interventions: A Quantitative Evaluation of Physiotherapy Treatment Approaches’ in Zambia. Indonesian
Journal of Disability Studies (IJDS).2020: Vol. 7(1): pp. 92-100.
Stroke Disability and Physiotherapy Interventions:

A Quantitative Evaluation of Physiotherapy
Treatment Approaches’ in Zambia
*
Muatle Mpemba, Hstings Kachingwe Shula, Brian Chanda Chiluba
The University of Zambia, School of Health Sciences, Department of Physiotherapy PO Box 50110, Lusaka, Zambia
Abstract Worldwide, cerebrovascular accidents (stroke) are the second leading cause of death and the third
leading cause of disability. As a result of physical disability after stroke, most of the patients need
physiotherapy. Due to different backgrounds, knowledge, clinical experiences, personal preferences, and
continually developing clinical practices, physiotherapists use different methods to treat their stroke patients.
This study was designed to determine physiotherapists’ perspective on the physiotherapy interventions for
stroke patients at the University Teaching Hospital and Levy Mwanawasa University Teaching Hospital in
Lusaka. This was a descriptive, cross-sectional study which was quantitative in nature. Data was collected
through a standardized questionnaire with modifications to fit the scope of the study. A total of 36
participants consisting of 23 Physiotherapists and 13 physiotherapy Technologists from both hospitals
contributed to the study, giving an overall response rate of 78.3 percent. The data obtained was analyzed by
using descriptive analysis and chi-square test was used to test the association. The results showed that
PNF/Brumstrom (92%) was the most taught approach among the respondents in their professional education.
The preferred treatment approaches in stroke rehabilitation which are used by Physiotherapists and
physiotherapy Technologists are repetitive functional task practice (72%), motor learning (69%) and
PNF/Brumstrom (67%). The choice of a particular technique to use in practice was based on clinical
experience (91.7%), presentation of the patients (88.9%) and Theoretical knowledge (86.1%). The main
contributing factor to not choosing certain treatment approaches were lack of training (86.1%), concept of the
treatment approach not being clear (75.0%) and lack of equipment (69.4%). Out of 36 respondents 27 were
involved in continuing education on stroke rehabilitation and 9 were not involved. There is need to
incorporate the newer physiotherapy treatment approaches into the physiotherapy practice as the scope of
practice that reflects the latest evidence base improves the provision of services and contributes to better and
cost-effective physiotherapy interventions for stroke patients.
Keywords: Physiotherapy intervention, Treatment approach, Stroke, physiotherapy, Rehabilitation
1. Introduction assistance or are fully dependent on caregivers

for activities of daily living (ADL) after stroke
Worldwide, stroke and its disability (Miller et al., 2010). Over the last four
correlates are the second leading cause of decades, the incidence of stroke in low- and
death and the third leading cause of disability middle-income countries has more than
(World Health Organization, 2012). Stroke doubled (Feigin et al., 2014). With the
may affect physical, cognitive, social, and improvement in healthcare, more people
emotional functioning. Stroke recovery is survive stroke and then have to cope with the
heterogeneous in terms of outcome, and it is negative physical, psychological, social, and
estimated that 25% to 74% of the 50 million functional sequelae (Opara & Jaracz, 2010).
stroke survivors worldwide require some However, in Zambia the actual incidence and
prevalence of stroke have not been
* Corresponding author: Muatle Mpemba established.
[email protected]
Published online at http://IJDS.ub.ac.id/ As a result of physical disability after
Copyright © 2020PSLD UB Publishing. All Rights Reserved stroke, most of the patients need
Received, November 11, 2019 Revised, May 14, 2020 Accepted, May 15, 2020
IJDS 2020; Vol. 7 No. 1, May 2020, pp. 92-100
ISSN: 2355 – 2158 e-ISSN: 2654-4148
physiotherapy. Physiotherapy remains the key This was a descriptive, cross-sectional

component of stroke rehabilitation focusing study and quantitative in nature. Data was
on the recovery of physical function and collected through a standardized questionnaire
enhancement of independent living. A variety
with modifications to fit the scope of the
of physiotherapy interventions improve
functional outcomes, even when applied late study. The questionnaire was based upon the
after stroke (Ferrarello et al., 2011). published survey in the field of stroke
Treatment of hemiplegia after stroke rehabilitation. It was developed by Natarajan
continues to be a challenging and often et al., (2008). The questionnaire was also used
frustrating experience for clinicians. In the in a study by Umair et al., (2014) in Pakistan
past, stroke services have been criticized for to understand the current clinical practices in
being poorly coordinated and providing
stroke rehabilitation in Lahore (Chuni, V,
insufficient therapy, information, and support
(Rahman et al., 2012). Chiluba, Mwango, Nkandu, Shula, 2018).
Over the years, various approaches to 2.2 Study materials

physical rehabilitation have been developed, The study was conducted at the adult
according to different ideas about how people Physiotherapy department of the University
recover after a stroke (Pollock et al., 2014). Teaching Hospital and Levy Mwanawasa
These approaches have been adopted by University Teaching Hospital. The University
physiotherapists in stroke rehabilitation. Teaching Hospital (UTH) is the biggest
Physical rehabilitation, comprising a selection government owned hospitals in Lusaka
of components from different approaches, is followed by the Levy Mwanawasa University
effective for recovery of function and mobility Teaching Hospital. The two hospitals are the
after stroke. Due to different backgrounds, most financed from the state budget and have
knowledge, clinical experiences, personal more staff members. The targeted study
preferences, and continually developing population included all the Physiotherapists
clinical practices, physiotherapists use and physiotherapy Technologists working at
different methods to treat their stroke patients the mentioned hospitals (18 from LMUTH
(Umair et al., 2014). and 28 from UTH). The sample size of the
study included all physiotherapists and
Disability and Rehabilitation literature
physiotherapy technologists working in these
is evolving with every passing day; therefore,
selected health facilities in Lusaka.
reading literature should be an integral part of
Convenience sampling method was used in
their professional responsibility. Moreover, it
this study. A verbal and written informed
helps the clinician to choose up-to-date
consent was obtained before giving the
interventions in order to improve effective
questionnaire to respondents. The
rehabilitation practices for their patients.
questionnaire did not contain any personal
(Umair et al., 2014). Sanjib & Rinat (2013)
questions. Therefore, it did not pose any threat
stated that having qualifications in
to participants’ confidentiality in any way.
physiotherapy does not always mean that the
However, an identification number was
physiotherapist is delivering good practice.
assigned to each questionnaire to protect the
Physiotherapists should have sound
identity of the participants.
knowledge of current issues on physiotherapy.
This means that they must have up to date 2.3 Statistical Analysis
knowledge about new techniques for better
The data was analyzed using the SPSS
practice. This study was designed to
software for analyzing quantitative research
determine physiotherapists’ perspective on the
data. The data collected was coded in numeric
physiotherapy intervention for stroke patients
form for processing and was entered on the
at the University Teaching Hospital and Levy
version 22 spread sheet. Data was analyzed
Mwanawasa University Teaching Hospital in
descriptively by computing the frequencies
Lusaka.
and percentages for categorical variables.
2. Research Methodology Results were expressed in frequency and
2.1 Study design percentage. A Chi square test with a
significance of p <0.05 was used to determine
93
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IJDS 2020; Vol. 7 No. 1, May 2020, pp. 92-100
ISSN: 2355 – 2158 e-ISSN: 2654-4148
the relationship between treatment approaches (67%). The least practiced was constraint
taught in professional education and treatment induced (11%) and high intensity therapy
approaches currently being practiced. The (19%).
research was approved by the University of
Zambia, School of Health Sciences Table 1. Demographic Distribution of the
Undergraduate Research Ethics Committee. respondents (n=36)
Permission to conduct the study was granted
Demographic Percentage
by the hospital managements of the mentioned Frequency
hospitals. Permission letters from the hospital Characteristics (%)
management was submitted to the Sex
physiotherapy Head of Departments of the Male 13 36.1%
mentioned hospitals and the participants gave Female 23 63.9%
informed consent. Age
21 - 30 years 9 25.0%
3. Results and Discussion 31 - 40 years 18 50.0%
3.1 Participants’ demographics 41 - 50 years 9 25.0%
characteristics 51 - 60 years 0 0.0%
This study was designed to determine 61 & Above years 0 0.0%
physiotherapists’ perspective on the Profession
physiotherapy interventions for stroke patients attainment
at the University Teaching Hospital and Levy Diploma 13 36.1%
Mwanawasa University Teaching Hospital in Degree 20 55.6%
Lusaka. A total of 36 respondents participated Masters 3 8.3%
in this study, giving an overall response rate PhD 0 0.0%
of 78.3 percent.
Years of treating
Table 1 summarizes the demographic stroke patients
distribution of the respondents. Of the 36 0 - 5 years 9 25.0%
respondents 23 (63.9%) were females and 13 6 - 10 years 13 36.1%
(36.1%) were males. The age for most of the 11 - 15 years 6 16.7%
respondents was between 31 and 40 years 16 - 20 years 4 11.1%
(50.0%). Out of the 36 respondents, 3 had 20 and above
masters, 20 had degree qualifications and 13 4 11.1%
years
had diploma. Most of the respondents 13
(36.1%) had been treating stroke patients for The focus in the cross tabulation (table 2) was
about 6 to 10 years. to assess the relationship between treatment
approaches taught in professional education
3.2 Treatment Approaches in Stroke and treatment approaches currently being
Rehabilitation practiced. It was noted that the treatment
Figure 2 shows that PNF/Brumstrom approaches that were mostly practiced are
(92%) was the most taught approach among those approaches that were mostly taught. A
the respondents, followed by motor learning chi square test was done and the following
(78%), repetitive functional task practice were significant at p=0.05; Bobath/NDT
(75%) and Bobath/NDT (72%). A few were (0.006), Repetitive functional task practice
taught constrained induced (22%), high- (0.011) and bilateral arm training (0.000)
intensity therapy (25%) and functional while PNF/Brunnstrom (0.213) and motor
electrical stimulation (39%) in their learning (0.078) were not significant.
professional education. Even though Furthermore, the results show that the
PNF/Brumstrom was the most learned approaches that were rarely taught were rarely
treatment approach, it was noted that practiced among the respondents. The
repetitive functional task practice (72%) was following were statistically significant; Carr &
the most common treatment approach of Shepard (0.001), mirror therapy (0.000),
choice among the respondents followed by functional electrical stimulation (0.000) and
motor learning (69%) and PNF/Brumstrom high-intensity therapy (0.000) while constraint
94
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IJDS 2020; Vol. 7 No. 1, May 2020, pp. 92-100
ISSN: 2355 – 2158 e-ISSN: 2654-4148
Induced (0.363) was not significant.
approaches taught in school training mostly used treatment approach

100% 92%
90%
78% 75%
80% 72% 72%
67% 69%
70% 64%
61% 61%
60%
47%
50% 44%
39% 42%
40%
30% 25% 22% 25% 25%
19%
20%
11%
10%
0%
n
d
g
g
y
m
T
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io
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ap
ap
D
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Re
Fig 1. Stroke treatment approaches taught in school training and mostly used in practice (n=36). (NB: The
total percentage was not adding up to 100% because respondents were allowed to choose multiple
treatment approaches).
Table 2. The relationship between Treatment approaches taught in professional education and treatment
approaches currently practiced (n=36).
Treatment approach used in practice

Treatment approach taught in school P value
Mostly Rarely Never Total
Bobath/NDT 0.006
Yes 20 (55.6%) 4 (11.1%) 2 (5.6%) 26 (72.2%)
No 2 (5.6%) 4 (11.1%) 4 (11.1%) 10 (27.8%)
PNF/Brunnstrom 0.213
Yes 23 (63.9%) 8 (22.2%) 2 (5.6%) 33 (91.7%)
No 1 (2.8%) 1 (2.8%) 1 (2.8%) 3 (8.3%)
Total 24 (66.7%) 9 (25.0%) 3 (8.3%) 36 (100.0%)
Carr and Shepherd 0.001
Yes 8 (22.2%) 7 (19.4%) 2 (5.6%) 17 (47.2%)
No 1 (2.8%) 5 (13.9%) 13 (36.1%) 19 (52.8%)
Motor Learning 0.078
Yes 22 (61.1%) 3 (8.3%) 3 (8.3%) 28 (77.8%)
No 3 (8.3%) 2 (5.6%) 3 (8.3%) 8 (22.2%)
Constrained Induced 0.363
Yes 2 (5.6%) 1 (2.8%) 5 (13.9%) 8 (22.2%)
No 2 (5.6%) 5 (13.9%) 21 (58.3%) 28 (77.8%)
Repetitive functional task practice 0.011
Yes 23 (63.9%) 2 (5.6%) 2 (5.6%) 27 (75.0%)
No 3 (8.3%) 3 (8.3%) 3 (8.3%) 9 (25.0%)
95
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ISSN: 2355 – 2158 e-ISSN: 2654-4148
Treatment approach used in practice

Treatment approach taught in school P value
Mostly Rarely Never Total
High-intensity therapy 0.000
Yes 6 (16.7%) 3 (8.3%) 0 (0.0%) 9 (25.0%)
No 1 (2.8%) 5 (13.9%) 21 (58.3%) 27 (75.0%)
Functional electrical stimulation 0.000
Yes 8 (22.2%) 4 (11.1%) 2 (5.6%) 14 (38.9%)
No 1 (2.8%) 5 (13.9%) 16 (44.4%) 22 (61.1%)
Mirror therapy 0.000
Yes 13 (36.1%) 1 (2.8%) 1 (2.8%) 15 (41.7%)
No 3 (8.3%) 3 (8.3%) 15 (41.7%) 21 (58.3%)
Bilateral arm training 0.000
Yes 20 (55.6%) 1 (2.8%) 1 (2.8%) 22 (61.1%)
No 3 (8.3%) 4 (11.1%) 7 (19.4%) 14 (38.9%)
NB: The total percentage was not adding up to 100% because respondents were allowed to choose multiple
treatment approaches.
36 respondents 27 (75%) were involved in Personal

69.4% 5.6% 25.0% 100%
continuing education on stroke rehabilitation preference
and 9 (25%) were not. Table 3 shows that Clinical
91.7% 0.0% 8.3% 100%
majority of the respondents agreed to all the experiences
statements presented regarding the factors that Presentations
88.9% 2.8% 8.3% 100%
influence their choice of a particular treatment of the patients
approach. Most of the respondents (91.7%) Theoretical
86.1% 5.6% 8.3% 100%
indicated that clinical experience influenced knowledge
their choice of a particular treatment approach Time taken to
followed by presentation of the patients perform a 58.3% 16.7% 25.0% 100%
(88.9%) and Theoretical knowledge (86.1%). technique
Time taken to perform a treatment technique Continuous
developing
had less influence on choosing of a particular 83.3% 8.3% 8.3% 100%
clinical
treatment approach.
practices
Table 4 revealed that lack of training (86.1%),
lack of equipment (69.4%), treatment
Table 4 Factors contributing to not choosing a
approach with no clear concept (75.0%) and particular treatment approach (n=36)
treatment approach less effective (58.3%)
contributed to most of the respondents not Factors
choosing certain treatment approaches. While contributing
majority of the respondents disagreed that lack to not
of time to perform an approach (50.0%) and choosing a Agree Unsure Disagree Total
approaches not being simple to perform particular
(41.7%) contributed to not choosing a treatment
particular treatment approach. approach
Lack of
Table 3. Factors that influence the respondents’ 86.1% 0.0% 13.9% 100%
training
choice of a particular treatment Lack of
approach (n=36) 69.4% 8.3% 22.2% 100%
equipment
Factors Concept of a
influencing technique 75.0% 2.8% 22.2% 100%
the choice of a not clear
Agree Unsure Disagree Total Not simple
particular
treatment techniques to 38.9% 19.4% 41.7% 100%
technique perform
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Lack of time 4. Discussion

to perform a 38.9% 11.1% 50.0% 100% Knowledge about views of
technique
physiotherapists regarding current stroke
Approach
58.3% 11.1% 30.6% 100% rehabilitation methods is very important in
less effective
planning health policies and in conducting
continuing education programs in this field
3.3 Respondents Involvement in (Rahman et al., 2012). In order to understand
continuing education on stroke the current physiotherapy interventions in
stroke rehabilitation, this study was conducted
rehabilitation
to determine physiotherapists’ perspective on
Figure 2 shows that out of 36 respondents 27 the physiotherapy interventions for stroke
(75%) were involved in continuing education patients at the University Teaching Hospital
on stroke rehabilitation and 9 (25%) were not and Levy Mwanawasa University Teaching
involved. Hospital in Lusaka.
According to figure 3 it was noted that 25% of The study revealed that PNF/Brunnstrom
the respondent’s study stroke-related literature was the most taught approach among the
every week while 47.2% study about once a respondents in their professional education
month and 27.8% reported that they rarely followed by motor relearning and repetitive
read stroke related literature. functional task practice. In contrast to our
study results, a study by Umair et al. (2014) in
The results show that 71.4% (n=15) of Pakistan found that most of the respondents
physiotherapy practitioners have strongly received PNF and Carr & Bobath training in
heard of OGA and a gait assessment tool and Universities. Another study done by Natarajan
14.3% (n=3) had never heard of OGA or any et al. (2008) within the states of Kansas and
assessment tool. Missouri found that nearly all the respondents
were taught PNF/Brunnstrom and Bobath
training in Universities.
The preferred treatment approaches in
stroke rehabilitation which are used by
Physiotherapists and physiotherapy
Technologists are repetitive functional task
practice, motor relearning and
PNF/Brunnstrom. Similar studies done found
that preferred approaches to treat stroke
patients was Carr and Shepherd and
PNF/Brunnstrom methods (Umair et al.,
Fig 2. Respondents involved in continuing 2014). A study done in Saudi Arabia by
education on stroke rehabilitation (n=36)
Alqahtani et al. (2018) found that
47,2 Physiotherapists preferred Bobath approach
50
40
for stroke rehabilitation over newer
25 27,8 techniques. In comparison to the preferred
30
20 treatment approach, a review by Lin and
10 Dionne, (2018) found that the following
0 interventions possess credible evidence to
Every week about once a Rarely improve functional movement of persons with
month
stroke: cardiorespiratory training, therapeutic
Percent exercise (ie, strengthening), task-oriented
training (task-specific training), constraint-
induced movement therapy (CIMT), mental
Fig 3. Respondents study on professional literature
practice, and mirror therapy. Evidence
on Stroke (n=36). indicates that physical rehabilitation should
not be limited to compartmentalised, named
approaches, but rather should comprise clearly
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ISSN: 2355 – 2158 e-ISSN: 2654-4148
defined, well‐described, evidenced‐based therapists and relevant presentations of the

physical treatments, regardless of historical or patients. Clinical experience with good
philosophical origin (Pollock et al., 2014; theoretical knowledge that is evidence based
Chiluba e al., 2019). can produce an effective treatment protocol
that will contribute to a better and cost-
This study showed that only a few were
effective stroke rehabilitation.
taught CIMT and was mostly used in practice
by a minority. Similar results were reported in On the factors affecting the choice of
a study by Alqahtani et al. (2018) who found certain treatment approaches, most of the
that only a quarter of therapists learned respondents indicated lack of training, concept
constraint-induced movement therapy (CIMT) of the treatment approach not being clear, lack
in their college and only a few used CIMT. of equipment and less effective approaches.
However current literature strongly supports Furthermore, majority of the respondents
the use of CIMT. A study by Batool et al. indicated that lack of time and approaches not
(2015) revealed that CIMT proved to be more being simple to perform did not contribute to
statistically significant and clinically effective not choosing a certain treatment approach.
intervention in comparison to motor Contrary to this study, a study by Bayley et al.
relearning programme among the patients (2012) found that the most commonly noted
aged between 35-60 years. Furthermore, Khan barrier to implementation was lack of time
et al. (2011) concluded that constraint induced followed by staffing issues,
therapy seems to be the optimal approach to training/education, therapy selection and
improve arm and hand function and minimize prioritization, equipment availability and team
the risk of shoulder pain for patients with functioning/communication. Alqahtani et al.
minimal to moderate arm hand function after (2018) found that two thirds of the clinicians
stroke in the intermediate term. responded that time and availability of
resources were the common barriers among
Chi-square tests were done to determine
clinicians which influence the choice of stroke
the relationship between treatment approaches
rehabilitation.
taught in professional education and treatment
approaches currently being practiced. The With regards to continuing education, the
study revealed that the treatment approaches study showed that three quarter of the
that were mostly taught in professional respondents were involved in continuing
education were mostly practiced among the education on stroke rehabilitation. Although
respondents. Bobath/NDT, Repetitive most of the respondents are involved in
functional task practice and bilateral arm continuing education on stroke rehabilitation,
training were statistically significant. it is clear from the study results that the
However, PNF/Brunnstrom and motor current treatment approaches that have been
relearning were not significant. Furthermore, studied and are recommended rehabilitation
the study revealed that the treatment approaches for improving motor outcome are
approaches that were rarely taught in rarely practiced. This could suggest that the
professional education were rarely practiced respondents had challenges with translating
among the respondents. Carr & Shepard, knowledge into practice and Menon et al.
mirror therapy, functional electrical (2010) found that personal barriers, such as
stimulation and high-intensity therapy were the lack of confidence and skills to interpret,
statistically significant while constraint synthesise and apply research findings, limited
Induced was not significant. clinicians' uptake of best practices (Chiluba &
Njapawu, 2019).
Most of the respondents, their choice of a
particular technique to use in treatment was Concerning how often respondents’ study
based on clinical experience, presentation of professional literature on CVA/stroke
the patients and Theoretical knowledge. These rehabilitation, it was noted that a quarter of
results may support what Abdullahi et al. the respondent’s study stroke-related literature
(2016) stated in their study that the choice of a every week while about half of the respondent
particular technique by physiotherapists may study about once a month and more than a
not be evidence based, but rather from quarter reported that they rarely read stroke
personal preference, experience of the related literature. Umair et al. (2014) found
98
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that less than quarter of the participants was analyzed by MM and all authors
studied stroke-related literature frequently approved the final manuscript submission.
while a few rarely and more than three
quarters of therapists reported that they never References
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Stroke Disability and Physiotherapy Interventions: A Quantitative Evaluation of Physiotherapy Treatment Approaches' in Zambia

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IJDS 2020; Vol. 7 No. 1, May 2020, pp.

Stroke Disability and Physiotherapy Interventions:

Keywords: Physiotherapy intervention, Treatment approach, Stroke, physiotherapy, Rehabilitation

1. Introduction assistance or are fully dependent on caregivers

physiotherapy. Physiotherapy remains the key This was a descriptive, cross-sectional

Over the years, various approaches to 2.2 Study materials

Induced (0.363) was not significant.

approaches taught in school training mostly used treatment approach

Treatment approach used in practice

Treatment approach used in practice

36 respondents 27 (75%) were involved in Personal

Lack of time 4. Discussion

defined, well‐described, evidenced‐based therapists and relevant presentations of the

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