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Physician Awareness of Physical Medicine and Rehabilitation: A Cross-Sectional Study from Saudi Arabia
Maher Al Jadid*, Maryam S Alibrahim, Nadiah M Almutairi, Hayat A Al Harbi, Reem Abdelhalim, Adel S Aldhuwaila and Sarah Farhoud
Department of Rehabilitation Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia

ABSTRACT
Aim
To ascertain physicians awareness levels regarding the specialty of Physical Medicine and Rehabilitation (PM&R) in Saudi Arabia.

Methods
A cross-sectional study involving 200 randomly-selected practicing physicians (aged 25-60 years; 114 males) at the Prince Sultan Military Medical City, Riyadh, Saudi Arabia, from October 2016 to February 2017. A structured questionnaire was employed for data collection.

Results
The study cohort (n=200) were a mean (±SD) age of 33±1.82 years, with 86% in the 25-35 year age category, and 43% female. The vast majority of the physicians (185 or 92.5%) responded that they were aware or had heard of PM&R and 110 (55%) routinely referred their patients for PM&R care. Of note, 40 (20%) of the physicians felt that PM&R was similar to physical therapy. Of the physicians who were aware of PM&R, 146 (73%) physicians reported improvements in their patients with PM&R care and 176 (89.5%) physicians stated that specialized medical doctors were necessary for rehabilitation.

Conclusion
This study identifies a high level of awareness and satisfaction among Saudi physicians regarding PM&R services.
KEYWORDS
Awareness; Physical medicine and rehabilitation; Saudi Arabia

Introduction
According to the World Health Organization (WHO), rehabilitation is “The use of all means aimed at reducing the impact of disabling and handicapping conditions and at enabling people with disabilities to achieve optimal social integration” [1,2]. An all-inclusive account of Physical and Rehabilitation Medicine (PRM) or Physical Medicine & Rehabilitation (PM&R), has been clearly recognized and refers to the medical specialty dealing with rehabilitation as the core of its health approach [3].

The PM&R or Physiatry deals with the prevention, diagnostics and treatment of disabling diseases, disorders, and injuries, by using physical methods (such as electrotherapy, therapeutic exercise or pharmaceutical pain control) [4]. The American Board of Physical Medicine and Rehabilitation defines the PM&R specialist as one who is an expert in nerve, muscle and bone, who gives treatment for injuries or illnesses that affect body movement, who diagnoses and treats pain, who restores to the maximum any function that has deteriorated or been lost due to injury, illness or disabling conditions, who treats the entire person and not merely the affected area, who leads a team of medical professionals, offering non-surgical treatments, and who clearly outlines the patient’s medical conditions and a suitable strategy of treatment/prevention [5].

This medical discipline assists patients in regaining the ability to manage their lives through re-established body function. Therefore, PM&R offers treatment to patients with traumatic injury, post-surgery or those affected by diseases that induce impairments through disorders of the musculoskeletal or nervous systems, chronic pain or restricted movement [2,6-8]. The treatments typically involve physical therapeutics, medications and/or non-invasive or marginally invasive techniques [9]. The chief focus in PM&R is to enable the individuals to function optimally within the limitations they experience. PM&R consultants act as team leaders and draw up plans and approaches to facilitate the greatest possible functional recovery for the patients. Physiotherapists, occupational therapists, speech and language therapists, psychologists, orthotists and prosthetists form an integral part of this team [2,6]. While the focus of the team is not on complete restoration to the premorbid level of function, optimization of the quality of life is the goal for those unable to reach a complete level of restoration [9,10].

As the population within the Kingdom of Saudi Arabia (KSA) has increased and aged, disability has also risen, with greater numbers of systemic, congenital diseases and traumatic (i.e., vehicular injury) injuries. These factors have created an increased demand for PM&R services and a concordant need for higher levels of awareness for PM&R in the KSA [11-14]. Over the past two decades, several rehabilitative services for individuals with disabilities and other residents have been set up by the KSA Ministry of Health (MOH) throughout the country, however, most of these programs provide physical, occupational, speech and hearing therapy only. Recently, studies have reported an increasing need for more rehabilitation centers, physicians trained in rehabilitation medicine and for teams of rehabilitation professionals in Saudi Arabia [13]. Limited research has been done on PM&R and physician awareness of PM&R in Saudi Arabia. In the current study, the objective was to ascertain the level of physician awareness of PM&R in KSA.
Methods
A cross-sectional study was conducted among 200 randomly selected physicians (aged 25-60 years; 114 males) at the Prince Sultan Military Medical City, Riyadh, Saudi Arabia, from October 2016 to February 2017. A structured questionnaire was employed for data collection.

The questionnaire included details on the physicians, including; gender, age, specialty, ranking according to the Saudi Commission for health specialties, source of their awareness of PM&R, knowledge about differences between PM&R and physical therapy, whether they had ever recommended PM&R care for a patient or followed up with the patient post-referral to PM&R care, opinion on patient improvement after PM&R care, opinion regarding the requirements for PM&R referral, necessity for a specialized physician to deliver PM&R care and the need for an increased numbers of rehabilitation hospitals to be established in Saudi Arabia.
Statistical Analysis
Utilizing Microsoft Excel 2010 (Microsoft Corporation, Seattle, WA, USA) and the statistical package for social sciences version 22 (SPSS Inc., Chicago, IL, USA), the data were analyzed. Besides the descriptive analysis, the differences within the group were identified using the chi-square test.
Results
A description of the study population is presented in table 1. The 200 physicians involved in the study cohort showed a mean (±SD) age of 33±1.82 years, with 43% of the physicians were female. A large percentage (86%) of the study population was in the 25-35 year age group; 82% of the physicians were residents, 13% were medical specialists (registrars and senior registrars) and 5% were consultants.

In figure 1, the physician response to PM&R is shown. A total of 185 (92.5%) physicians reported being aware and/or heard about PM&R, while 40 (20%) responded that PM&R was identical to physical therapy. In all, 110 (55%) physicians had referred their patients to undergo PM&R treatment.

From the physicians referred in this study, 92 (46%) stated that they followed up with their referred patients, 146 (73%) physicians reported patient improvement post PM&R care, while 176 (89.5%) physicians emphasized the need for a specialized medical doctor for rehabilitation care. In fact, 90% of the total physicians expressed that Saudi Arabia requires a greater supply of rehabilitation hospitals (Figure 1).

Table 2 lists the physician responses and associated factors (such as, physician gender, age, specialty and rank) connected with PM&R awareness. The question “Have you ever referred patients to Physical Medicine and Rehabilitation care?” elicited significant results, as did age (p<0.028) and physician specialty (p<0.029).
Discussion
To our knowledge, this study is the first estimate of the extent of knowledge among the physicians in Saudi Arabia regarding PR&M. Including PRM (PM&R) in the standard medical training program has been introduced in a few countries (e.g., Australia, Belgium, Canada, France, Spain, Sweden, USA , and UK) [2]. In a recent study of medical providers in Poland, 404 (80.8%) respondents were found to deem PRM as a fundamental medical specialty. They also recognized the present insufficiency of knowledge and inadequacy of awareness among Medical Students (MS) and Non-PRM Specialists (NPRMS) of the role of PRM in the health care system [15]. In the current study, it was observed that 55% of physicians referred their patients to PM&R care, a finding which concurred with the earlier reports [16]. The majority noted improvements in patients with PM&R care and the need for additional PM&R physicians and centers. In light of the range of investigative queries posed in the questionnaire, the results imply a moderate level of awareness regarding PM&R in the all the groups of respondents.

In another study performed in KSA to identify the attitudes of the general practitioners to PM&R, it most of the participants (92.2%) expressed insufficiency of knowledge imparted in musculoskeletal education in the general practitioner training courses and 84.3% had not studied disabilities at all [17]. Among the respondents, 56.8% had visited at least one disabled patient during the previous month, while 11% had upwards of 10 during the same time period. General practitioners indicated that the musculoskeletal physical examination was the most required educational field [17]. This study found that 93 physicians had some awareness and/or had heard about PM&R and 82% reported that PM&R was different from physical therapy. Additionally, 90 physicians stated the need for specialized medical doctors for rehabilitation. In fact, 90% of the physicians responded that Saudi Arabia urgently required a greater number of rehabilitation hospitals. In a recent research done to ascertain the knowledge levels of the Medical Students (MS) and Non-PRM Specialists (NPRMS) on the part played by PRM in health care system, it was clear that the knowledge of the definition of an individual having a disability and PRM was meager (MS: 58% and 35%; NPRMS: 39% and 30% PRMT: 72% and 62%), which concurs with current study [2].

Some limitations have been observed in this study, including its cross-sectional characteristic, and also that the study was limited to a single hospital. More studies, conducted on a larger scale, are required to overcome these limitations.
Conclusion
This study identifies a high level of awareness and satisfaction among Saudi physicians regarding PM&R services. The PM&R services must be expanded and proven to be a significant medical specialty that can be offered to traumatized or ill patients. Therefore, we recommend that in the future, further studies be accomplished to confirm the results of this study.

References
  1. World Health Organization (2001) International Classification of Functioning, Disability and Health (ICF). World Health Organization, Geneva, Switzerland.
  2. Tederko P, Krasuski M, Denes Z, Moslavac S, Likarevic I (2016) What medical doctors and medical students know about physical medicine and rehabilitation: a survey from Central Europe. Eur J Phys Rehabil Med 52: 597-605.
  3. Momsen AM, Rasmussen JO, Nielsen CV, Iversen MD, Lund H (2012) Multidisciplinary team care in rehabilitation: an overview of reviews. J Rehabil Med 44: 901-912.
  4. https://www.merriam-webster.com/dictionary/physical%20medicine%20and%20rehabilitation
  5. American Academy of Physical Medicine and Rehabilitation (2017) What is a physiatrist? American Academy of Physical Medicine and Rehabilitation, Chicago, USA.
  6. Gutenbrunner C, Ward AB, Chamberlain MA (2009) Re: the dream of a medical specialty named physical and rehabilitation medicine: a commentary on the European White Book of Physical and Rehabilitation Medicine. Am J Phys Med Rehabil 88: 1037-1039.
  7. Stucki G, Bickenbach J, Gutenbrunner C, Melvin J (2017) Rehabilitation: The health strategy of the 21st century. J Rehabil Med
  8. https://www.jrcptb.org.uk/specialties/rehabilitation-medicine
  9. Dawson PU (2009) A new discipline in medicine, physiatry: physical medicine and rehabilitation. West Indian Med J 58: 497-498.
  10. Bal S, Oz B, Gurgan A, Memis A, Demirdover C, et al. (2011) Anatomic and functional improvements achieved by rehabilitation in Zone II and Zone V flexor tendon injuries. Am J Phys Med Rehabil 90: 17-24.
  11. Mahmoud H, Qannam H, Zbogar D, Mortenson B (2017) Spinal cord injury rehabilitation in Riyadh, Saudi Arabia: time to rehabilitation admission, length of stay and functional independence. Spinal Cord 31: 509-514.
  12. Robert AA, Zamzami MM (2013) Traumatic spinal cord injury in Saudi Arabia: a review of the literature. Pan Afr Med J 16: 104.
  13. Al Jadid MS (2011) Rehabilitation medicine in the Kingdom of Saudi Arabia. Saudi Med J 32: 962-963.
  14. Aleisa E, Al-Sobayel H, Buragadd S, Rao MG (2014) Rehabilitation services in Saudi Arabia: An overview of its current structure and future challenges. J Gen Practice 2: 184.
  15. Tederko P, Krasuski M, Nyka I, Denes Z (2015) [Knowledge of physical and rehabilitation medicine among physicians and medical students in Poland]. Wiad Lek 68: 123-131.
  16. Raeissadat SA, Samadi B, Rayegani SM, Bahrami MH, Mahmoudi H (2014) Survey of medical residents' attitude toward physical medicine and rehabilitation. Am J Phys Med Rehabil 93: 540-547.

Raissi GR, Mansoori K, Madani P, Rayegani SM (2006) Survey of general practitioners' attitudes toward physical medicine and rehabilitation. Int J Rehabil Res 29: 167-170.

Figures


Figure 1: Response of the physician about Physical Medicine and Rehabilitation.

Tables

Variables

n, %

Gender

Male

114 (57%)

Female

86 (43%)

Age

25-35 yrs

172 (86%)

36-45 yrs

17 (8.5%)

46-60 yrs

11 (5.5%)

Specialty

Medical

150 (75%)

Surgical

39 (19.5%)

Others

11 (5.5%)

Ranking in Saudi commission for health specialties

Resident

164 (82%)

Specialist/registrars

13 (6.5%)

Senior registrars

13 (6.5%)

Consultant

10 (5%)

Table 1: Description of the study participants.

(a) Gender vs Physician Responses

Responses

Male

Female

P value

Have you ever heard of the physical medicine and rehabilitation specialty?

Yes

104

81

0.307

No

10

5

Physical medicine and rehabilitation is the same as physical therapy?

Yes

27

13

0.92

No

87

73

Have you ever referred a patients to physical medicine and rehabilitation care?

Yes

65

45

0.303

No

49

41

Have you ever referred a patients to physical medicine and rehabilitation care? If yes, did you follow up the patients afterward

Yes

52

40

0.507

No

62

46

Did your patient improve after physical medicine and rehabilitation care?

Yes

87

59

0.146

No

27

27

Do you think rehabilitation needs specialized medical doctor?

Yes

101

78

0.406

No

13

8

 

(b) Age vs Physician Responses

Responses

25-35 yrs

36-45 yrs

46-60 yrs

P value

Have you ever heard of the physical medicine and rehabilitation specialty?

Yes

157

17

11

0.267

No

15

0

0

Physical medicine and rehabilitation is the same as physical therapy?

Yes

35

3

2

0.954

No

137

14

9

Have you ever referred patients to physical medicine and rehabilitation care?

Yes

89

11

10

0.029

No

83

6

1

Have you ever referred patients to physical medicine and rehabilitation care? If yes, did you follow up the patients afterward

Yes

79

7

6

0.785

No

93

10

5

Did your patient improve after physical medicine and rehabilitation care?

Yes

124

12

10

0.384

No

48

5

1

What you think: Rehabilitation needs specialized medical doctor?

Yes

152

16

11

0.385

No

20

1

0

 

(c) Specialty vs Physician Responses

Responses

Medical

Surgical

Others

P value

Have you ever heard of the physical medicine and rehabilitation specialty?

Yes

136

39

10

0.14

No

14

0

1

Physical medicine and rehabilitation is the same as physical therapy?

Yes

33

3

4

0.52

No

117

36

7

Have you ever referred a patients to physical medicine and rehabilitation care?

Yes

85

22

3

0.164

No

65

17

8

Have you ever referred a patients to physical medicine and rehabilitation care? If yes did you follow up the patients afterwards

Yes

61

25

6

0.028

No

89

14

5

Did your patient improve after physical medicine and rehabilitation care?

Yes

107

30

9

0.622

No

43

9

2

What you think: Rehabilitation needs specialized medical doctor?

Yes

133

37

9

0.368

No

17

2

2

 

(d) Ranking vs Physician Responses

Responses

Resident

Consultant

Senior Register

Specialist Register

P Value

Have you ever heard of the physical medicine and rehabilitation specialty?

Yes

149

10

13

13

0.318

No

15

0

0

0

Physical medicine and rehabilitation is the same as physical therapy?

Yes

33

0

3

4

0.318

No

131

10

10

9

Have you ever referred a patients to physical medicine and rehabilitation care?

Yes

83

8

9

10

0.6

No

81

2

4

3

Have you ever referred a patients to physical medicine and rehabilitation care? If yes did you follow up the patients afterwards

Yes

72

6

7

7

0.632

No

92

4

6

6

Did your patient improve after physical medicine and rehabilitation care?

Yes

117

8

10

11

0.689

No

47

2

3

2

What you think: Rehabilitation needs specialized medical doctor?

Yes

145

10

11

13

0.357

No

19

0

2

0

Table 2: Physician responses about PM &R awareness and association of age, gender, specialty and ranking.

Citation: Jadid MA, Alibrahim MS, Almutairi NM, Harbi HAA, Abdelhalim R, et al. (2018) Physician Awareness of Physical Medicine and Rehabilitation: A Cross-Sectional Study from Saudi Arabia. J Phys Med Rehabil Disabil 4: 023.