Factors affecting compliances with physiotherapy among stroke patients: physiotherapist's perspective: a study from Peshawar Pakistan.
V O L .
Factors affecting compliances with physiotherapy among stroke patients: physiotherapist's perspective: a study from Peshawar Pakistan.
Rabia Basri 0 1
University of Peshawar,Peshawar, Pakistan
0 Abasin University , Peshawar , Pakistan
1 Khyber Medical University , Peshawar , Pakistan
Factors affecting compliances with physiotherapy
among stroke patients: Physiotherapist's perspective:
A study from Peshawar Pakistan.
1Department of Physiotherapy, Khyber Medical University, Peshawar, Pakistan
2Department of Zoology, University of Peshawar,Peshawar, Pakistan
3Department of pharmacy, Abasin University, Peshawar, Pakistan
Date of submission: March 17, 2017 Date of revision: May 12, 2017 Date of acceptance: May 25, 2017
Back ground/Aim: Non-compliances to physiotherapy are common. Outside the Western nations, little is known to
the factors responsible for non-compliances with physiotherapy. This study aimed to evaluate the factors affecting
non-compliances with physiotherapy among stroke patients, in Peshawar, Pakistan.
METHOD: Seven in practice physiotherapists from Peshawar, Pakistan, were invited to focus group discussion to
discuss their opinions about factors affecting stroke patient's non-compliances and the strategies to manage with
these factors. The dialogues were transcribed and analyzed. Significant words and statements describing
noncompliances were identified. The cluster of meanings developed and used to write a combined description
presenting the real meaning of discussion.
RESULTS: The main factors identified were: misconception about physiotherapy, poor awareness and poor
infrastructure for physiotherapy, poor communication among healthcare providers, economical issues, social and
cultural factors and factors related to exercise education. The patient and family education shaped the basis of
many of these strategies recognized by the physiotherapists to help the patients, manage non-compliances.
CONCLUSION: The physiotherapists in Peshawar identified some barriers to treatment compliances in case of
stroke rehabilitation. They also developed some strategies which they believe as supportive in encouraging
motivation that is unique to Pakistani social and cultural context. The other barriers to treatment compliances and
strategies, identified as key to enhancing adherence in Western countries were not highlighted by the focus group
of this study.
KEY WORDS: Barriers, Misconception about physiotherapy, Rehabilitation.
The term compliance has been defined before as the
extent to which a person adopts the lifestyle based on
medical and health care recommendations . The
World Health Organization (WHO) define compliance
as “the extent to which a person's behavior
corresponds with agreed recommendations from a
health care provider” . Other terms being suggested
for the compliance are the adherence, maintenance
and patient cooperation . Better treatment outcomes
can only be accomplishing if patients closely follow
their health care recommendations . Types of
compliance which has been studied before included,
clinical appointments specifically for chronic
conditions, self-control regimens as in hypertension
and diabetes, taking medications and adherence to
exercise programs . In Western countries,
noncompliances with treatment approaches are some
trouble across all disciplines of health care including
physiotherapy. For example, only two-third (2/3) of
patients were found adherent with short-term
exercise regimes and this may be poorer for
longterm therapy recommendations and for unsupervised
home based exercise programs . In case of
physiotherapy, the patient may need multiple
sessions depending upon a condition for better
recovery' . Physiotherapists therefore commonly face
problems of non-compliance with treatment program
from all over the world. Suggested by the literature,
there may be some reasons for non-compliance with
exercise treatments' . For example, low-level of
physical activity, low self-efficacy, low social support,
anxiety, increased pain levels initially with exercise
treatments are certain barriers to adherence with
physiotherapy . Ethnicity may influence attitude,
behavior, and beliefs around the pathology and
physical activity e.g, Chinese show more negative
attitude about future results of low back pain
compared with Australians . Asian population may be
less likely to adhere with physiotherapy programs
P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S 2 6
which encourage increased level of exercises or
physical activities .
The compliances with physiotherapy among stroke
sufferers may be poorer. The stroke sufferer may lose
independent state due to part(s) of brain damage,
depends upon the extent of the damage. The barriers
to compliances with physiotherapy in a case of stroke
can be internal and external . As reported, 80% to 90%
of stroke population suffers from limb(s) weakness
which hinders them from moving independently. The
other factors which can contribute to making some one
dependent are disturbed coordination, loss of balance,
severe depression and fatigue, these factors reported
commonly in stroke patients . The external factors
which act as a barrier to therapy compliance for them
are a close availability of physiotherapy centers and
wheelchairs usage .
The role of ethnicity and cultural issues in
noncompliances are the important areas for investigation.
Increasing the understanding of these factors can help
physiotherapists to develop the strategies that can
overcome these factors for patient's effective
management. The aim of this study was to investigate
the physiotherapist's perceptions about factors
influencing patient's compliances in outpatient
department in Peshawar, Pakistan
It was a qualitative study, based on the grounded
theory approach. Male and female physiotherapist
having five years of experiences in stroke rehabilitation
centers of Peshawar were invited for the focus group
discussion. The preference was given to
neurophysiotherapists for the study selection but, that was
optional criteria for inclusion. The physiotherapists with
experience of inpatient stroke rehabilitation were
excluded. The indoor follow-up may be easy for stroke
patients compared to those within the community.
2.2. STUDY PARTICIPANTS:
The physiotherapists were invited from different
hospitals and clinical setups via email using
information sheets. Information sheets consisted brief
description of focus group discussion and its date, time
and venue. The participants encouraged to ask
anything about a study, prior to the discussion. All of the
physiotherapists were ensured of confidentiality prior
coming to the focus group discussion. The
nonprobability convenience sampling was used due to
time constraints. Twenty physiotherapists responded
positively to the study. The 8 participants were selected
by inclusion and exclusion criteria. Factors influencing
to stroke patient's adherence with physiotherapy
rehabilitation within Peshawar setups were discussed.
The views of physiotherapist were collected and
recurring themes were elaborated.
2.3. STUDY PROCEDURE:
Among eight invited physiotherapists, one did not
arrive for discussion while all other participants sat
around a table in way of full view of one another. The
participants requested to share their opinions. The
chair or the moderator of the group discussion (MN)
was one of the authors of the study and was the
nonmedical person. She only facilitated the group
discussion but did not give any thoughts to the
discussion. The modified standard guidelinesusedfor
the focus group discussion which were same, as used
by Marwaha et al, (Table 1).
Interviewing guideline (Table 1)
1. Have you ever come across the patients whom
you find non-adherent to prescribed exercise
plane in any way?
2. Have you ever supervised the treatment plane of
patients in follow up, if yes, were they following
each component correctly?
3. What are the reasons that act as barrier to patients
compliances in your opinion?
4. Can you list the barriers in a rank from major
barriers to the minor one?
5. What could be the best possible strategies in your
opinion to cope up the above scenario?
The discussion was recorded on two tapes. The
primary researcher, who was also physiotherapist did
not participate in focus group discussion (refers to
eligibility criteria of the study), she only assisted the
moderator in study data recording.
The information was taken about physiotherapist
perceptions of non-compliances with exercise
treatment of stroke population and they discussed the
best possible strategies to overcome these factors..
Data collection: Two tape recorders were used for
recording of focus group discussion.
The Mean age ± Standard Deviation (SD) and the
Mean length of experience ± SD were computed for
study participants. The study participants also
evaluated in terms of educational background and kind
of organization (Government, semi-government,
private or Non-Government Organizations (NGO)
where they experienced such non-adherent cases.
The focus group discussion was interpreted by one of
the study author (AN), who was not the part of focus
group discussion. Data were analyzed in the four main
stages. Stage 1: A thorough listening for the discussion
to have a sense of overall meaning. Stage 2:
Identification of significant words and sentences
P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S
explained the reasons for non-compliances. Stage 3:
The meaning of significant words and sentences were
compelled to major study themes. Stage 4: The major
study themes were explained in the context of
physiotherapist's perceptions of non-compliances.
4.1. PARTICIPANT'S CHARACTERISTICS:
The Mean age of study participants was 34±4.5 years
and their Mean length of experience was 6±1.5 years.
Out of seven members, five were specialized in the
neuro-physiotherapy field. There were two females
and five male participants in focus group discussion.
Two physiotherapists were from government
organizations, one from semi-government while
remaining all had experience of private setups.
4.2. MAJOR STUDY THEMES:
The seven major study themes are emerged from the
discussion and are given in Table 2.
Major themes (Table 2)
1. Misconception about physiotherapy
2. Poor awareness
3. Poor communications among health care providers
4. Social barriers
5. Cultural barriers and economical barriers
6. Tendency to forget exercises
7. Stroke based symptoms
4.2.1. MISCONCEPTION ABOUT
The participants identified following misconception
about physiotherapy in our society.
a) The general populations are less aware to
physiotherapy in Peshawar, the patients often
consider the physiotherapy as same as to massage
therapy and they insist for massage plan rather than
exercise plan in case of treatment by physiotherapy.
b) The fitness exercises or the activities of daily life
which require exertions are often considered as same
as to exercises prescribed by the physiotherapists.
c) Some of the people consider the physiotherapy as a
sole method of treatment by modalities however heat
therapy is most popular with them. The patients insist
for heat modalities even if heating is contra-indicated
to their condition, they get to dissatisfy if the
physiotherapists use the alternate methods of patient
care. The patients need to be fully educated by the
therapist about the mechanism of their problems and
the mechanism of cure by physiotherapy. A
physiotherapist can use alternate modality if heating
contraindicates to patient's condition and can later
add it after signs of contraindication.
4.2.2. POOR AWARENESS:
The physiotherapists identified that our population is
not aware to:
a) Many of the health problems
b) The aims and therapeutic approaches of
c) Access to physiotherapy
d) Authentic health professionals
Importantly in our population, the most famous are the
“Saints” or “Baba's” who promise them for their cure,
based on unauthentic resources, as the stroke patients
are commonly reported to be visited by them. This all
factors are due to low literacy rates in Pakistan, the
only small sections in urban population are educated
and they are also equipped with the sufficient
information about their pathological conditions.
4 . 2 . 3 . P O O R C O M M U N I C AT I O N A M O N G
General Practitioners (GPs) do not acknowledge
physiotherapy in our society and they insist patients for
their own therapeutic plans even if they need
physiotherapy. Sometimes the GPs refer a patient to
the physiotherapist with prescribed physiotherapy e. g,
heat therapy; the addition of any exercise plan by the
physiotherapist in that particular situation sometimes
creates the problem because most of the patients only
want to stick to GP recommendation. The medical
curriculum needs to incorporate the subjects related to
physiotherapy for better understanding its role in
The physiotherapists explained the social support in
the following context
a. The female of our society are highly depended on
male family members for support in many aspects of
life including concerns of health. They may suffer in
case if their supporters are not cooperative.
b. There are attitudinal barriers as people from
backward areas often consider the stroke and other
diseases as punishment from God. This may boost up
depression which is commonly reported with stroke.
c. Recovery from stroke highly depends on family
support especially in case of acute condition; the
physiotherapist requires family and patient motivation
for exercises. The slow recovery from stroke usually
makes family tired and less adherent with exercises for
a patient. According to physiotherapists these barriers
now thought to be changing due to awareness for
many health problems. The media and education are
playing role in lifting up the women in our society but
this will take time. The phenomena of circuit training
P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S
and group training which are newly introduced to
stroke patients are getting popular due to patient's
motivation and their high compliances with this kind of
The existed 'Purdah ' system in our society have set
the mind of women to get treatment only by a female
therapist, tagging some personal belief with religion
make them hinder from participating in a proper
rehabilitation program. Much of the population of
Peshawar is under the poverty line; the long term
multidisciplinary treatment of stroke additionally
makes the financial burden on patients. The
Government and non-Government institutions are
required to address those cultural issues and
4.2.6.THE TENDENCY TO FORGET EXERCISES:
Most of the patients mention forgetfulness as one of
the reason for non adherence with physiotherapy. In a
majority of our setups, the physiotherapists educate
the patient for exercises on exercise sheets which
consist of exercise image, its repetitions and other
necessary information relevant to patient's condition.
The low literacy rate and less interest in exercises
usually create this kind of situation. T
The exercises should be supervised in that case for
better recovery. The therapist can provide the patients
with exercise videos in their native languages if the
individual patient supervision is not possible to the
4.2.7.STROKE SPECIFIC SYMPTOMS AS A
According to physiotherapists, there are some stroke
specific symptoms which can affect patient's
adherence with exercises. Depression, mood
disruption, cognitive problems, and aphasia are some
among these symptoms. Stroke patients suffer from
the energy crisis and they spend most of the day part
inactive while mean time, the physiotherapists need
their active participation in exercises. The external
factors that can contribute to not adherence with
exercises in stroke population are, need for a wheel
chair (depending upon the patient's condition), hospital
location and dependency on an environment. The
developments of more and more stroke centers are
now trying to cope up with these factors.
The current study evaluated the perceptions of
Pakistani physiotherapists about the factors for
noncompliance with physiotherapy rehabilitation among
stroke patients. The barriers identified were a
misconception of physiotherapy, poor awareness,
poor communications among health care providers,
cultural and economic factors and social barriers.
Factors for non compliancesthat found unique to our
population were a misconception of physiotherapy,
women dependency on men, stigmas for disabilities,
and famous concept of “saints” and “Baba's” in health
recovery, existed a system of “purdah” and poor
economic status of a general population. This study
a l s o i d e n t i fi e d t h a t s o m e f a c t o r s f o r n o n
complaincesare due to stroke condition. For example,
physical status after stroke, depression, negative
emotions and less tolerance to exercises are some
factors that make stroke patient's non adherent with
exercises. Some other studies also identified a low
physical status, poor exercise history, poor exercise
organization and poor leadership as a major barrier to
a d h e r e n c e w i t h e x e r c i s e t r e a t m e n t .
A study conducted by Marwaha et al., to examine the
perception of Indian physiotherapist about factors
affecting patient's compliance with physiotherapy' .
According to this study forgetfulness, treatment time
and treatment cost were main barriers responsible for
non adherence. Sluijs et al. , in Holland and Alexandre
et al., reported that a barrier which influences heart
patient's decision for cardiac rehabilitation is actually
their concomitant medical illness. They found afraid of
their weak hearts. All of these studies suggested that
health care professionals need to understand these
factors for effective management of patients and thus
reducing the burden on the healthcare system. Medina
et al. reported that physiotherapist in Spain perceives
their patients well adherent to physiotherapy initially, at
times of pain and gradually they decrease with
compliances . According to Spain' physiotherapist, the
patients consider physical and social barriers to
compliances with physiotherapy specifically in chronic
phases .Some other studies were conducted
previously to find the prevalence of adherent patients
with physiotherapy. The Kolt GS, McEvoy JF in 2002
investigated the prevalence of adherent patient with
back pain physiotherapy over 4-week training
sessions, they reported 87% of patients regular with
their appointments and only 72% were found adherent
to home based plans . This study in contrast to these
studies investigated the factors for non compliances.
According to some other studies, compliance rate
varied from 10% -85% depending upon disease
nature, affected the population, prescribed treatment
regimen and it also depends on the word compliance
A few numbers of studies reported the socio-economic
status as a barrier to adherence with treatment, this
might be due to the fact that majority of these studies
conducted in the Western nation where health
insurances take the responsibility of treatment cost of
their citizen . However, a study from India, Holland and
this current study do not exclude socioeconomic status
as a barrier to adherence with treatment' Increasing
the awareness for diseases, incorporating the subject
of physiotherapy in medica l syllabus, empowering the
woman through education, development of more
health centers in cities and peripheries, reducing the
cost of treatment at private set-ups and highlighting the
wrong concept of “saint” in recovery through media
were some suggestions of this study to cope up with all
these factors of non adherence. The majority of these
elements can be fixed if health care system pays
attention to the development of physiotherapy council
The factors, affecting stroke patients compliances with
physiotherapy in Peshawar, Pakistan are poor
awareness, considering physiotherapy as similar to
massage therapy, misconception of routine activities
as therapeutic exercises, poor communication among
health care providers, and abundance of faith healers,
patient's forgetfulness to exercises, poor economic
status and cultural and societal barriers.
The data of this study only consisted verbal information
while the non-verbal language and tone were not
analyzed which may convey meaningful information.
The study only justifies the perspective of few
physiotherapists and only for stroke condition from
Peshawar; the results, therefore, cannot be
generalized to the whole Pakistan.
The future studies can investigate the treatment
compliance with musculoskeletal rehabilitation. The
patients' perspective ofnon complianceswith
physiotherapy should be investigated to have a clearer
p i c t u r e o f t h e b a r r i e r s p e r c e i v e d b y t h e
physiotherapists in this study.
7. Hogan M, Kelly C. THE CLINICAL EFFECTS OF
I N T E N S I V E , S P E C I F I C E X E R C I S E O N
P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S 3 0
Conflict of interest: Author declares no conflict of interest.
Funding disclosure: Nil
Rabia Basri; concept, data collection, data analysis, manuscript writing, manuscript review
Maryam Naseen; data collection, data analysis, manuscript writing, manuscript review
Aatika Naz; data analysis, manuscript writing, manuscript review
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