Perception, knowledge, and attitude of medical doctors in Saudi Arabia about the role of physiotherapists in vestibular rehabilitation: a cross-sectional survey

Study design

The study was conducted based on the STROBE checklist for cross-sectional studies (Appendix S1). Thirteen-hundred members of the Saudi Commission for Health Specialties (SCFHS) with different specialties, designations, nationalities, and work experience, working in various hospitals in 13 regions of Saudi Arabia, were invited to participate in this study. Medical doctors were invited through email to participate in the survey. The study commenced in April 2021 and completed in September 2021. The study was approved by the Institutional Review Board of Majmaah University (MUREC-April. 7/COM-2021/31-1). Medical doctors received an email that contained a link to the survey and a consent form. Additionally, human resource departments of hospitals for contacted to distribute the survey among medical doctors.

Participants

All licensed medical doctors working in KSA were entitled to take part in the survey. The participants did not receive any incentives for participation. Email addresses of the participants were retrieved from the hospital website or by contacting the human resource department of the hospital. Participants received informed consent forms through email, which included all survey-related information as well as contact information of the correponding author. For two months, non-responsive participants were reminded every two weeks. Further communication was stopped, if the participants did not answer after four reminders.

Sampling method

Stratified sampling was used to uniformly collect data from medical doctors working in 13 provinces of Saudi Arabia. There are 226 hospitals recognized by Ministry of Health Saudi Arabia, with a vast difference in the number of hospitals in each of the 13 provinces. Therefore, a proportionate sampling method was employed to obtain a homogenous sample depending on the number of hospitals in each province. To obtain an optimal sample size of 371 medical doctors, 10% of hospitals were randomly selected from each province. For example, four hospitals were randomly picked from 48 hospitals in Riyadh province, accounting for 10% of the total hospitals in the province. A total of 23 hospitals were randomly selected from a computer-generated random number assigned to 226 hospitals in 13 provinces across the country. An official invitation letter was sent to each hospital’s human resource department to disseminate the survey among medical doctors. A total sample size of 1,231 medical doctors were invited to participate, and 381 medical doctors responded, giving a response rate of 30.9%

Survey questionnaire development

The questionnaire was developed by a team of experts in vestibular management (6 medical doctors, one language expert, and 2 senior physiotherapists) and piloted among ten medical doctors before distribution. Cronbach’s alpha for the reliability of the questionnaire was 0.843. The survey questions were inserted into the Qualtrics survey software, and the questionnaire link was provided to medical doctors through email.

The survey comprised seven sections and 23 questions; the first section contained ten general items (questions 1–10), the second section comprised questions related to vestibular patients (questions 11–13), and the third section consisted of questions related to the attitudes and knowledge of medical doctors regarding physical therapists’ role in vestibular disorders (questions 14–18). if the medical doctors answered that they did not see the patient with vestibular patients, the questionnaire was terminated after collecting demographic information. The fourth section consisted of questions related to referral (question no. 19). The fifth section consisted of one question related to the involvement of physiotherapists in the management of different vestibular conditions (question no. 20). The sixth section consisted of questions related to the perception of medical doctors about assessment and maneuvers effectively applied by a physiotherapist (question no. 21–22). Finally, the seventh section consisted of one question related to feedback obtained from medical doctors about the approach of a physiotherapist with patients with vestibular disorders (question no. 23) (Appendix S2).

Sample size calculation

The sample size was determined from the online Raisoft sample size calculator (Inc, 2020) and based on the response rate of 50%, a confidence interval of 95%, and a margin of error of 5%, with a total medical doctors population of around 113,146 as per the 2019 census (Health, 2019). Therefore, the sample size required was 377.

Statistical analysis

IBM SPSS version 20 (IBM Corp., Armonk, NY, USA) was used to analyze the data. Qualitative data were analyzed as frequencies and percentages, nominal data by binomial test, and multiple responses by chi-square test at a threshold value of 50%. Logistic regression was used to estimate the effect of nationality, experience, specialty, and workplace on the referral practices and perceptions of doctors about the role of the physiotherapist in vestibular rehabilitation. A P < 0.05 was considered statistically significant.

Demographic data of medical doctors

A total of 381 medical doctors participated in the study, with a response rate of 30.9% (Fig. 1). The data were collected from 381 medical doctors, with nearly equal participation from male (n = 187, 49.15%) and female medical doctors. The highest participation came from the 24–30-year-old age group (n = 111, 29.1%) and the lowest from the 60 years and over age group (n = 61, 16%). The majority of the medical doctors were native Saudi citizens (n = 158, 41.5%), and those from Canada or America made up the smallest percentage (n = 1, 0.3%) (Fig. 2). The most common specialization was dentistry (n = 90), followed by ENT (Ear Nose Throat) (n = 85), and the least common was gastroenterology (n = 1) (Fig. 3). The highest number of medical doctors reported that they obtained their last degree from Saudi Arabia (n = 119, 31%) and the least from the Philippines (n = 1, 0.9%) (Fig. 4). The highest number of participants were from Riyadh province (n = 122, 32%) and the least from the northern border (n = 13, 3.4%) and Asir province (n = 13, 3.4%) of Saudi Arabia (Fig. 5). The majority of medical doctors were practicing at a government hospital (n = 255, 66.9%). One hundred ninety-three (50.7%) medical doctors reported managing and treating the patients with vestibular disorders, and the plurality (n = 154, 40.4%) of them reported managing and treating less than five patients in a month (Table 1). The common vestibular condition seen by medical doctors was benign paroxysmal positional vertigo (n = 169, 87.6%), and the least common was vestibular migraine (n = 33, 17.1%) and mal de barquement (n = 33, 17.1%) (Fig. 6).

The attitude of 193 medical doctors who were involved in management of patients with vestibular conditions

Medical doctors reported that the most preferred medical professionals for managing patients with the vestibular disorder were ENT specialists (n = 173, 72.1%), followed by physiotherapists (n = 30, 12.5%), and the least preferred were nurses (n = 12, 5.0%) (Table 2). Friedman’s two-way analysis of variance by ranks showed a statistically significant difference in the proportion of medical doctors reporting preferred healthcare professionals for the management of patients with vestibular disorders (ENT, Audiologist, nurse, PT, OT), χ2(4) = 482.476, p = 0.001. The pairwise comparison Bonferroni alpha adjustment between health professionals revealed a significant difference between OT vs. ENT (p = 0.001), Nurses vs. ENT (p = 0.001), Audiologist vs. ENT (p = 0.001), and PT vs. ENT (p = 0.001).

Knowledge of 193 medical doctors about the role of the physiotherapist in vestibular assessment, diagnosis, and treatment

Out of 193 medical doctors, 163 (84.5%) responded to the question related to role of physiotherapist in assessment and treatment and remainder 30 (15.5%) responded in favor of physiotherapist. Out of 177 mutually inclusive responses from 163 respondents, (n = 156, 80.8%) medical doctors were not aware of the role of the physiotherapist in the assessment and diagnosis of a patient with vestibular disorders. The remainder of the 21 responses from the medical doctors stated that a lack of confidence (n = 10, 5.2%), lack of experience (n = 6, 3.1%), and insufficient knowledge among physiotherapists (n = 5, 2.6%) were the primary barriers. Similarly, out of 193 medical doctors, 155 (80.3%) responded to the question related to role of physiotherapist in treatment of patient with vestibular rehabilitation, remainder 30 (15.5%) responded in favor of physiotherapist and 8 (8%) choose not to respond to the question due to unknown reason. Out of 156 mutually inclusive responses from 155 medical doctors (n = 145, 75.1%) were not aware of the role of the physiotherapist in the treatment of a patient with vestibular disorders and the remainder reported less experience (n = 9, 4.7%) and insufficient knowledge among physiotherapists (n = 2, 1.0%) (File S1).

Logistic regression was performed to estimate the effects of nationality, specialty, experience, and workplace on the likelihood that medical doctors reported that physiotherapists are capable of assessing, diagnosing, and treating patients with vestibular disorders. The logistic regression model was statistically significant, χ2(30) = 76.343, p = 0.001. The model explained 56.5% (Nagelkerke R2) of the variance among medical doctors and correctly classified 90.7% of cases. Medical doctors with 1–5 years of experience are 7.165 (95% CI [1.104–46.515]) times more likely to report that physiotherapists are involved in assessing, diagnosing, and treating patients with vestibular disorders than medical doctors with more experience. The other predictors such as nationality, specialty, and workplace were not significant.

Out of 193 medical doctors, 30 reported that physiotherapists could effectively apply assessment techniques in patients with vestibular disorders. The most frequently reported assessment technique that physiotherapists could effectively apply was the Dix Hill Pike maneuvers (n = 23, 11.9%), followed by the Dynamic Visual Acuity Test (n = 21, 10.9%), and the least was VOR-Cancellation (n = 16, 8.3%).

Out of 193 medical doctors, 30 reported that physiotherapists can effectively use maneuvers and exercises in patients with vestibular disorders. The most frequently reported maneuver that physiotherapists can effectively apply was the Semont maneuver (21, 10.9%), followed by the Canalith Repositioning maneuver (n = 20, 10.4%), and the least was the Barbecue roll maneuver (n = 11, 5.7%).

Perception of 193 medical doctors about the role of physiotherapist in different vestibular conditions

The majority of medical doctors reported no role of physiotherapists (78.4%), and merely 2.0% and 2.7% reported a role in assessment and treatment in common vestibular conditions, respectively. The majority of medical doctors reported no role of the physiotherapist in BPPV (78.8%), vestibular neuritis (87.6%), vestibular hypotension (80.3%), vestibular migraine (86%), Meniere’s disease (83.9%), multiple sclerosis (86.5%), mal de debarquement (1%), perilymphatic fistula (100%), cervicogenic dizziness (93.8%), vestibular involvement due to traumatic brain injury (94.3%), and motion sensitivity (86.0%). A relatively small number of medical doctors reported that physiotherapists are involved in assessment (0.5 to 4.1%) and treatment (0.5 to 13%) of patients’ vestibular conditions. BPPV was the most frequent vestibular condition in the assessment and treatment of which physiotherapists were thought to have a role.

Referral attitude of medical doctors

Out of 193, only 27 (14.0%) medical doctors referred vestibular cases to a physiotherapist. The majority of cases referred to physiotherapists were benign paroxysmal vertigo (23, 20%), and the least common types of cases were vestibular migraine (n = 1, 0.9%) and perilymphatic fistula (n = 1, 0.9%) (Table 3). Out of 27 referrals to physiotherapists, the highest number of referrals to physiotherapists were from Saudi national medical doctors (n = 16, 45.7%), followed by Indian medical doctors (n = 10, 28.6%). The majority of referrals to physiotherapist were made by general physicians (n = 11, 40.7), followed by ENT specialists (n = 5, 18.5%) (Fig. 7).

Feedback from the patient after treatment from the physiotherapist

The majority of medical doctors did not obtain feedback from patients (n = 168, 87%), and remainder reported their patients were moderately (n = 13, 6.7%) and highly (n = 12, 6.2%) satisfied with the treatment provided by the physiotherapists.

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) was the most preferred vestibular condition for referral to physiotherapists by medical doctors. However, the majority of medical doctors reported that they were not aware of the role of the physiotherapist in the management of patients with BPPV. Nevertheless, many researchers report recent advancements in the field management of BPPV by a physiotherapist. Similarly, a study conducted among 175 patients with BPPV reported that 79% of patients were cured within one week of treatment by the Semont maneuver and exercises for vestibular rehabilitation (Garcia, 2005). In addition, a recent study conducted of 314 patients with BPPV of the posterior canal found that 91% of cases showed significant improvement in two or fewer treatment sessions of Canalith repositioning maneuvers (Power, Murray & Szmulewicz, 2020). This implies that those patient with BPPV who adhere to exercise gets a additive benefits in symptoms.

In our study, we found a small percentage of medical doctors referring migraine-related dizziness to physiotherapists (Table 3). A study conducted in 2005 by Gottshall, Moore & Hoffer (2005) reported significant improvement among patients with idiopathic migraine-associated vertigo after vestibular rehabilitation therapy administered by the physiotherapist. The authors of the study also reported improvement in dizziness handicap, activities-specific balance confidence, dynamic gait, and computerized dynamic posturography measures among patients with migraine-associated dizziness. Medications used to prevent migraine- related dizziness are effectives but must be individualized based on age, side-effect, contra-indications and pre-existing conditions. However, exerises carry no side effects and are reported to improve the tolerance pain and quality of life in patients with migraine-related dizziness (Eggers, 2007).

Meniere’s disease is a chronic disorder of the inner ear resulting in balance and hearing impairment. In our study, few medical doctors reported that they were aware of the role of the physiotherapist in the management of Meniere’s disease. However, a study conducted in the UK among 360 participants with Meniere’s disease reported significant improvement among participants receiving vestibular rehabilitation and symptom control techniques as compared to the control group. The symptom control technique used in the study is a self-management technique to reduce the dizziness symptoms by habituation exercises and reduction of stress (Yardley & Kirby, 2006). Similarly, a study conducted among 26 patients with Meniere’s disease improved on posturography sensory organization test after vestibular physical therapy exercises (Gottshall et al., 2005). Therefore, physiotherapists can offer a useful and inexpensive self management techniques and exercises to patients with Meniere’s disease.

In our study, the majority of medical doctors reported that physiotherapists had no role in the management of a patient presenting with vestibular symptoms due to traumatic brain injury and multiple sclerosis. Vestibular symptoms such as dizziness and balance impairment associated with multiple sclerosis (Hebert et al., 2011; Lotfi et al., 2021) and traumatic brain injury have been reported in many studies (Akin et al., 2017; Fausti et al., 2009; Fife & Kalra, 2015; Gurley, Hujsak & Kelly, 2013). Dizziness and balance impairment associated with vestibular hypofunction (Hall et al., 2016b), vestibular neuritis (Strupp et al., 1998), mal de barquement (Cha, Deblieck & Wu, 2016), and perilymphatic fistula (Larem, Al Shawabkeh & Aljariri, 2021) can be effectively managed with various physical therapy modalities. A review study conducted in 2018 by Kundakci et al. reported that vestibular exercises are effective in patients with chronic dizziness (Kundakci et al., 2018). The evidence suggests that the physical therapy intervention complements the main course of treatment in patients with variety of vestibular disorders (Hall et al., 2016b). The physical therapy role in various disorders with associated vestibular symptoms would considerably reduce the medical cost. However, a robust research evidence is needed in vestibular rehabilitation about the reduction of medical cost because of addition of physical therapy intervention.

Referral and feedback from the patient

In our study, we found that only approximately one-third of medical doctors referred cases to a physiotherapist. A study conducted in Saudi Arabia of 108 physicians about their perception of physical therapy services reported that physiotherapists lack knowledge and skill to assess and treat patients (Alshehri et al., 2018). A study conducted among 282 patients with peripheral vestibular disease reported an average of late medical consultation after months or years from the onset of symptoms (Jáuregui-Renaud et al., 2013). A study conducted in the US reported low referral to physiotherapists for vestibular rehabilitation. However, retrospective medical records also found that there was a steady increase in PT referrals for vestibular disorders from 6.2% in 2006 to 12.9% in 2015 (Dunlap et al., 2020). However, a cohort study conducted among 2,374 patients with vertigo and dizziness reported that 61% used medication and 41.3% utilized PT services (Grill et al., 2014). The scope of physiotherapy in vestibular rehabilitation is limited in Saudi Arabia. There is a urgent need to inform medical doctors practicing in Saudi Arabia about the role of physiotherapists in vestibular rehabilitation. Moreover, telerahbilitation for patients with vestibular dysfunction would be a convenient addition during COVID-19 pandemic (Aloyuni et al., 2020).

Majority of medical doctors incolved in the management of patients with vestibular disorders were not aware about the physical therapist being trained in vestibular rehabilitation. The Saudi Arabian doctors may benefit not only from further education into benefits of physical therapy for their patients, but also behaviour change theories and approaches, so that they can better promote the physical therapy services to their patients. These approaches include education, training, and enablement (Geissler & Zeber, 2020). These interventions foster improved communication with other disciplines and enhance the management of vestibular patients by providing holistic and comprehensive care (Davis et al., 1999). A review article reported interactive and multifaceted continuous medical education programs and clinical decision support systems are beneficial in improving knowledge, utilization of resources, and enhancing patient outcome (Chauhan et al., 2017).

The majority of medical doctors did not obtain feedback from the patient after referral. A relatively small number of doctors reported that their patients were moderate to highly satisfied with the treatment provided by the physiotherapists.

Limitations

The cross-sectional study involved a relatively small population of medical doctors. However, the stratified sampling method ensured that the response was homogenously obtained across all 13 provinces in Saudi Arabia. The online questionnaire was a bit longer, which could create response bias or increase non-respondents due to the busy schedule of medical doctors. There was a relatively low response rate (30%) and approximately 50% of the medical doctors were not involved in the assessment and treatment of patients with vestibular disorders. These low response rates and relative equivalence in the medical doctors who are involved or not involved with patients with vestibular disorders, may affect the generalisation of these results to the population of Saudi Arabian doctors. However, the representative sample of medical doctors who participated in the study might be an unbiased reflection of the wider Saudi medical doctors. The unbiased nature of our results was further supported by the fact that data from medical doctors were uniformly collected from 13 provinces of Saudi Arabia with wide range of specialization and experience.