Disability and Rehabilitation

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Adherence of physical therapy with clinical

practice guidelines for the rehabilitation of stroke
in an active inpatient setting

Ajimsha M. S., Smithesh Kooven & Noora Al-Mudahka

To cite this article: Ajimsha M. S., Smithesh Kooven & Noora Al-Mudahka (2019) Adherence of
physical therapy with clinical practice guidelines for the rehabilitation of stroke in an active inpatient
setting, Disability and Rehabilitation, 41:15, 1855-1862, DOI: 10.1080/09638288.2018.1449257

To link to this article: https://doi.org/10.1080/09638288.2018.1449257

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DISABILITY AND REHABILITATION
2019, VOL. 41, NO. 15, 1855–1862
https://doi.org/10.1080/09638288.2018.1449257

REHABILITATION IN PRACTICE

Adherence of physical therapy with clinical practice guidelines

for the rehabilitation of stroke in an active inpatient setting
Ajimsha M. S., Smithesh Kooven and Noora Al-Mudahka
Department of Physical Therapy, Hamad Medical Corporation, Doha, Qatar

ABSTRACT ARTICLE HISTORY

Background: Clinical guidelines are systematically developed statements designed to help practitioners and Received 27 August 2017
patients to make decisions about appropriate health care. Clinical practice guideline adherence analysis is Revised 3 March 2018
the best way to fine tune the best practices in a health care industry with international benchmarks. Accepted 4 March 2018
Objective: To assess the physical therapist’s adherence to structured stroke clinical practice guidelines in
KEYWORDS
an active inpatient rehabilitation center in Qatar. Stroke; guidelines;
Setting: Department of Physical therapy in the stroke rehabilitation tertiary referral hospital in Qatar. physical therapy
Method: A retrospective chart audit was performed on the clinical records of 216 stroke patients dis-
charged from the active inpatient stroke rehabilitation unit with a diagnosis of stroke in 2016. The audit
check list was structured to record the adherence of the assessment, goal settings and the management
domains as per the “Physical Therapy After Acute Stroke” (PAAS) guideline.
Result: Of the 216 case files identified during the initial search, 127 files were ultimately included in the
audit. Overall adherence to the clinical practice guideline was 71%, a comparable rate with the studies ana-
lyzing the same in various international health care facilities. Domains which were shared by interdisciplin-
ary teams than managed by physical therapy alone and treatments utilizing sophisticated technology had
lower adherence with the guideline. A detailed strength and weakness breakdown were then conducted.
Conclusion: This audit provides an initial picture of the current adherence of physical therapy assessment
and management with the stroke physical therapy guideline at a tertiary rehabilitation hospital in the
state of Qatar. An evaluation of the guideline adherence and practice variations helps to fine tune the
physical therapy care to a highest possible standard of practice.

ä IMPLICATIONS FOR REHABILITATION

An evaluation of the guideline adherence and practice variations helps to fine tune the rehabilitation
care to the highest possible standard of practice.

Proper assessments of the relationship between the process of rehabilitation care and outcomes with
a comprehensive set of process indicators will improve the quality of the care.

An agreement needs to be established between rehabilitation teams engage in interdisciplinary stroke
care regarding the shared responsibilities and team functioning.

It is recommendable to develop a specialty based clinical practice guidelines that can be aligned at a
higher ‘comprehensive rehabilitation level’ to provide the best possible and evidence based stroke care.

Introduction base in the physical therapy profession has resulted in a rapid

Development and practice of clinical guidelines in health services
are generally considered important for improving and managing
the care process [1–4]. Within the last 15 years, there have been
great developments in the standardization of recommended clin-
ical guidelines for stroke care both at regional and national levels
across many countries worldwide [5]. Clinical guidelines are sys-
tematically developed statements designed to help practitioners
and patients to make decisions about appropriate health care [6,7].
There is evidence that adoption of clinical guidelines has a positive
impact on the quality and effectiveness of services and reduces
inequalities regarding access to healthcare [8–10]. The trend to
carry out evidence-based practice affects the profession of physical
therapy and is the subject of discussion in the physical therapy
community [11]. In the last two decades, the need for an evidence
increase in its body of knowledge [12].
The guidelines aim to reduce inappropriate variations in prac-
tice, promote the delivery of high quality, evidence-based health
care and improve cost-effectiveness by providing a convenient, up
to date and unbiased summary of published research to be imple-
mented in clinical settings [7,13–15]. There are only few published
clinical studies which specifically review the effect of strategies to
increase the implementation of physical therapy guidelines. In a
study by Rebbeck et al., [16] the effect of implementation of spi-
nal pain guidelines were reviewed. Although 14 trials were
included in the review, only three included physical therapy
interventions.
Adherence to clinical guidelines is a term used broadly in the
literature to refer to all factors that may influence the uptake of

CONTACT Ajimsha MS ajimshaw.ms@gmail.com Department of Physical Therapy, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
Supplemental data for this article can be accessed here.
ß 2018 Informa UK Limited, trading as Taylor & Francis Group
1856 M. S. AJIMSHA ET AL.
recommended best practice in accordance with research evidence.
Several studies have examined interventions to implement and
improve adherence to clinical guidelines [17–19]. Hubbard et al.,
[20] has reported encouraging relationship between the clinical
practice guideline (CPG) adherence with evidence-based stroke
guidelines and health related outcomes in post stroke rehabilita-
tion. Research conducted in countries such as the United
Kingdom (UK) [21,22–25], Australia [20,26,27] and New Zealand
[28,29] concludes that standards of stroke care could be more
aligned with guidelines. However, these studies discuss the stroke
care provided by Australian, United Kingdom and New Zealand
rehabilitation facilities and cannot be easily generalized to Middle
Eastern settings.
Recently, the physical therapy unit of the tertiary referral stroke
rehabilitation center in Qatar developed a physical therapy spe-
cific clinical practice guideline called “PAAS Guideline” (physical
therapy after acute stroke) to enhance the effectiveness and effi-
ciency of postacute stroke physical therapy care. The goal of the
PAAS guideline is to improve the quality, transparency, and uni-
formity of the physical therapy provided to patients whose main
diagnosis is a stroke, throughout the chain of integrated care, by
explicitly describing the physical therapist’s management of these
patients on the basis of scientific research, adjusted where neces-
sary on the basis of consensus among physical therapy experts.
The usage of evidence-based guidance as a quality indicator for
stroke care was a relatively new concept in Qatar. The present
study was aimed to analyze the adherence of physical therapy
with clinical practice guidelines for the rehabilitation of stroke in
an active inpatient setting by utilizing them as quality indicators
for an audit. It is of interest that most national stroke guidelines
that were now established were developed as a result of stroke
audits [5].
Methods
This study was carried out in the Department of Physical Therapy
in the stroke rehabilitation hospital in Qatar. A retrospective chart
audit was performed by utilizing the physical therapy evaluation/
reevaluation and stroke subspecialty forms available in the Cerner
millennium. The Research Ethics Committee of the Hamad Medical
Corporation reviewed the study and raised no objections from an
ethical point of view. In April 2017, a retrospective chart audit was
performed on male stroke patient files admitted in the rehabilita-
tion unit between first of March 2016 and 28 February 2017 using
an audit checklist, a design based on the Physical Therapy After
Acute Stroke guideline with a structure similar to one in Johnston
et al., [29] study.
The subdivisions of the chart audit checklist were selected
based on the assessment, goal settings and the four management
domains of PAAS (physical therapy after acute stroke) guideline,
namely (1). Functional mobility, strength and balance training, (2).
Gait and cardiovascular training, (3). Upper limb training, (4).
Cognitive and somatosensory training (Supplementary Table S1).
A pilot chart audit questionnaire was developed by the stroke
physical therapy team from the study group. As a part of test val-
idation, three physical therapy specialists with stroke rehabilitation
experience from other rehabilitation facilities were given the
designed questionnaire to trial on three randomly selected patient
files and later were asked to mark any questions that were unclear
to them when they were auditing the files. After this trial, a dis-
cussion session was organized to ensure that their understanding
of the audit questionnaire was the same as what was intended.
Two questions were adjusted based on the “internal pre-testing”
measure. Two separate audits were performed during the study
period by “internal and external” auditors. Internal auditors were
from the study group and external auditors were randomly
selected from the acute neuro rehabilitation facility of the mother
health organization. The results gathered by the internal and
external auditors were compared, which enabled any points of dif-
ference to be discussed and clarified between them. One minor
arrangement was suggested by the external auditors regarding
the goal setting and an explanation was coined in the point
“short term goals lead to long term goals”.
The clinical records of the patients who were in the stroke
pathway, admitted in the stroke rehab center as an inpatient for
at least 3 weeks with a diagnosis of ischemic stroke and dis-
charged with timely assessment, reassessment and discharge sum-
mary were retrieved from the Cerner millennium. Hemorrhagic
type of strokes, transient ischemic attack or patient with other
severe comorbidities necessitating alteration in the therapy dos-
age including cardiac, renal or musculoskeletal problems were
excluded from the audit. The selected and retrieved files were
checked for the presence of inpatient physical therapy initial
assessment, reassessments, stroke subspecialty forms, functional
independent measure forms and discharge notes.
The period of patient selection for the chart audit was decided
as one year and retrieved the files from Cerner Millennium with
date range from 1 March 2016 to 28 February 2017. The search
resulted in 216 patient files including 59 cases of hemorrhagic
stroke, five cases of hemorrhagic transformation, 11 patient files
with severe cardiac pathologies with ejection fraction less than
60%, two with severe osteoarthritis of the knee and one with
acute renal failure, resulting in 138 patient files of pure ischemic
origin. Eleven files were removed during the initial screening as it
was incomplete for a proper data acquisition and 127 files were
ultimately included in the audit. This represents about 59% of
total stroke admissions in the active inpatient stroke rehab unit
and representing 10% of the stroke incidence rate of the country [30].
This percentage of stroke events per year may be lower than the
studied population that has been used in an Australian audit
(16%) [27]. This is justifiable in a way that the current study
sample represents the acute ischemic stroke patients with
“rehabilitation potential” admitted in the active inpatient setting
(only), the milder and very severe cases were excluded from the
“active inpatient rehabilitation pathway”. Both the internal and
external auditors used the manually extracted data from the
Cerner millennium, analyzed and recorded it on the given Excel
spreadsheet separately. An audit numbering system was used for
the files to ensure confidentiality and the data entry was checked
thrice for missing data or mistakes.
Data analysis
Detailed demographic data were extracted from the patient files
as the first part. Details like age, nationality, comorbidities, admis-
sion in the acute medical setting, transfer and discharge to and
from active inpatient setting, follow-up status and type of stroke
with localization of the lesion were collected. The second part was
regarding the guideline adherence and goal setting. Details from
assessment, reassessment, discharge notes, stroke subspecialty
form and functional independent measure instrument form were
analyzed for this. If any of the guideline suggested assessment,
outcome measure (OM) use, goal setting or treatment documenta-
tion were incomplete, they were categorized as “not adhering”.
The second part had six sessions, (1). Assessment and goal setting,
(2). Outcome measure use, (3). Functional mobility, strength and
balance training, (4). Gait and cardiovascular training, (5). Upper
limb training and (6) Cognitive and somatosensory training. Any
 PHYSICAL THERAPY ADHERENCE WITH STROKE GUIDELINES 1857

Table 1. Characteristics of the patients. Session I: Assessment and goal setting

Characteristics Subtypes N or %
In this component, the presence of basic neurological measurement
Age 56 (SDa ± 10.4) years tools, S.M.A.R.T (Specific, Measurable, Attainable, Realistic, Timely)
Length of stay 32 (SD ± 4.8) days
Type of stroke model goal setting and its stepwise progression to long term goals
Ischemic stroke 71% in the assessment, reassessment and discharge notes as per the
Hemorrhagic stroke 27% guidelines were assessed. Five sub sessions were there in this ses-
tPAb Hemorrhagic transformation 2% sion checking the presence of [1] Basic neurological measurements
Ethnicity
Qatar 14% in assessment, reassessment and discharge, [2] Long term goal is
Asian 46% “S.M.A.R.T” [3] Short-term goals are S.M.A.R.T [4] Short-term goals
MENAc region 37% are leading to long-term goals and [5] Use of psychometric proper-
Others 3% ties in goal setting.
Exclusion
Hemorrhagic stroke 59
Notwithstanding that even one omission of a component in
tPA Hemorrhagic transformation 5 any of the reassessments resulted as “not adhering”, use of basic
Cardiac pathologies 11 neurological measurements showed 73% adherence. The adher-
Severe OAd 2 ence to the component one in the initial assessment was 88%.
Renal failure 1
Reassessments have the lowest adherence (57%) while it was 74%
Incomplete files 11
No of patients in the final audit list 127 in the discharge summary. The audit session checking the object-
a
SD ¼ standard deviation. ive long term goal “S.M.A.R.T” was shown 93% adherence while
b
tPA ¼ tissue plasminogen activator. the objective ‘short-term goals are S.M.A.R.T accumulated 67%
c
MENA ¼ Middle East and North Africa. adherence. This was due to the presence of multiple short-term
d
OA ¼ Osteoarthritis. goals set at different phases of the evaluation process. Missing of
any component in any of the reassessment was categorized “not
assessment and management received under the above headings met”. There was an average of three reassessments per patient
were categorized as adhering to the guidelines. other than initial evaluation and discharge, and therefore, the
The assessment part measured the presence of basic neuro- chance of getting a “not adhering” was high even one had a per-
logical measurement tools in the assessment, reassessment and fect two reassessments. The fourth objective “short-term goals”
discharge notes, S.M.A.R.T model (Specific, Measurable, Attainable, are leading to “long-term goals” showed an adherence of 90%
Realistic and Timely) goal setting and its stepwise progression to with the clinical practice guideline. Patients with severe disabilities
long-term goals as per the guidelines. The outcome measure use with minimal improvements only marked “not met” for this ses-
division was used to find out the usage of recommended out- sion. The final objective “usage of psychometric properties in goal
come measures. The management part was designed to analyze setting” was shown an alignment of 72%, which was considered
whether the treatment options applied for various impairments as “good adherence” as it was a new practice introduced by the
were in accordance with the PAAS (physical therapy after acute PAAS (physical therapy after acute stroke) guideline. The overall
stroke) guideline recommendations. Any other techniques or adherence of the “assessment and goal setting” defined as the
approaches which were documented, but with rationalization for adherence with all the five components to the PAAS guideline
its use were considered as adhered to the guidelines while with- was 79%.
out justifications were not. The percentage of adherence with the
recommended assessment and management for each session Session II: Outcome measure use
were calculated separately. The overall adherence was calculated
This session was used to find out the usage of recommended out-
as a mean of the percentage adherence of the six sessions and
come measures. physical therapy after acute stroke guideline rec-
rounded to the nearest whole number.
ommends eight outcome measures as mandatory or
recommended and 14 outcome measures as optional. “Use of at
least 80% of the recommended outcome measure and 40% of
Results optional outcome measure” was considered as “adhering” in the
Table 1 provides the details of the audited cases. Of the 127 files evaluation criteria. Eighty-nine percent of files have shown an
adherence to the recommended outcome measure usage and it
audited, all received physical therapy management in the same
was 71% with the optional outcome measure. The overall adher-
active inpatient rehabilitation setting following transfer from an
ence of the “outcome measure use” session to the physical ther-
acute care facility. Of the 216 case files identified during the initial
apy after acute stroke guideline was 80%.
search for the defined time, 27% were of hemorrhagic origin, 71%
ischemic type and 2% were ischemic patient transformed into
hemorrhagic after tissue plasminogen activator infusion. The Session III: Functional mobility, strength and balance training
mean age was 56 (SD ±10.4) years. Fourteen percentage patients PAAS (physical therapy after acute stroke) Guideline recommends
were younger than 45 years. The average length of stay in the usage of nine evidence-based approaches for improving func-
active inpatient rehabilitation was 32 (SD ±9.8) days. Fourteen per- tional mobility, strength and balance based on the patient’s
centages were Qatari and 86% were non-Qatari. The large prepon- impairments identified during the assessment and reassessments.
derance of non-Qatari patients were explained by the huge male The chart audit was designed to find out the usage of at least
work force represented in the country’s population [31] (Table 1). four out of nine of the recommended approaches in assessment,
The 127 files selected represented the pure ischemic variety with- reassessment and stroke subspecialty form of the patient file as
out major comorbidities as explained elsewhere. All the selected “adhering”. The recommended approaches in this session were (a)
files were put for detailed chart audit by using the chart audit Mobilization out of bed, (b) Functional sitting balance training, (c)
form to analyze the six components. Standing up and sitting down training, (d) Postural control with/
1858 M. S. AJIMSHA ET AL.
without visual feedback in various platforms, (e) Functional
strength training, (f) Activity-based balance training, (g)
Electromyographic biofeedback for the paretic leg, (h) Maintaining
ankle dorsiflexion by means of a standing frame or night splint
and (i) Hydrotherapy. The overall percentage of adherence to this
session was 93%. The 5% of files which did not meet the criteria
had only three approaches mentioned in the file and 2% had only
two approaches mentioned.
Itemwise analyses of the usage of different approaches were
also carried out. Sitting balance training and sit to stand usage
was 96% in all the cases followed by functional muscle strength
training (93%), activity-based balance training (91%), and postural
control with visual feedback in various platforms (89%). Usage of
night splint/standing frame was recorded in 23% of files while
mobilization out of bed was documented in 55% of the files.
Hydrotherapy usage was the least recorded one (18%). EMG bio-
feedback was not mentioned in any of the files as the facility was
not available in the unit.
Session IV: Gait and cardiovascular training
This session contains evidence-based recommendations for gait
and cardiovascular training and comprises 11 items. The chart
audit tool was designed to check the usage of at least 5 out of 11
approaches as “adhering”. Overall adherence to this session of the
guideline was 92%.
Adherence of the individual usage of the approaches in the
files were; body-weight supported treadmill training (46%), tread-
mill training without body-weight support (94%), over ground gait
training (96%), gait training in public spaces (72%), robot-assisted
gait training (0%), mobility training in virtual reality (0%), circuit
class training for walking (95%), systematic feedback on walking
speed (92%), walking aids to improve walking ability (64%), leg
orthoses to improve walking ability (33%), self-propulsion in a
hand-propelled wheelchair (98%). The lack of facility for robotic
and virtual reality training made it as 0%. The relatively reduced
usage of treadmill training with body weight support was noted
for the forthcoming change process cycle.
Session V: Upper limb training
This session in the physical therapy after acute stroke guideline
recommends 11 approaches to the gross motor recovery of upper
extremity. Same like session IV, 5 out of 11 approaches in any
part of assessment and reassessment stroke subspecialty form was
considered as adhering. Guideline adherence to this session was
moderate. Only 52% of the files met the criteria for adherence to
hand function. Electrostimulation of the paretic arm and hand
(12%), mirror therapy for the paretic arm and hand (26%), modi-
fied constraint-induced movement therapy and immobilization
(12%), were found to be the least used other than the “zero” per-
centage for virtual reality, robot-assisted and electromyographic
biofeedback items which were absent during the chart audit time.
The treatment approaches most commonly used in this domain
were, therapeutic positioning of the paretic arm (70%), prevention
or treatment of glenohumeral subluxation and/or hemiplegic
shoulder pain (68%), bilateral arm training (61%), training muscle
strength in the paretic arm and hand (55%) and circuit class train-
ing for the paretic arm (52%).
Session VI: Other
This domain was for rehabilitation of specific impairments such
as cognitive, somatosensory or vestibular dysfunctions.
Six approaches were mentioned in this domain for the manage-
ment of issues like attention or memory deficits, hemispatial
neglect, recreation, dyspraxia, somatosensory and vestibular dys-
functions. Since these domains were more attributable to specific
dysfunctions that would be different from patient to patient, a
chart audit tool to find out its adherence was almost impossible.
The chart audit tool was redefined for this session as “usage of at
least two approaches in any part of the assessment/reassessment
sessions of the file”. Only 31% of the files has shown guideline
adherence in this session. The item analysis of the usage of spe-
cific approaches reveals that 31% of the files mentioned the
rehabilitation for hemispatial neglect, 36% used vestibular rehabili-
tation for their patients. The interventions to improve somatosen-
sory functions of the paretic leg or hand was mentioned in 19%
of the files. Cognitive rehabilitation for attention or memory defi-
cits (13%), interventions aimed at learning/re-learning and resum-
ing leisure or social activities in the home setting (10%) and
training for dyspraxia to improve activities of daily life-independ-
ence (9%) were used the least.
Discussion
The physical therapist’s adherence to structured stroke clinical
practice guidelines in the stroke inpatient rehabilitation center in
Qatar was found as 71% with varying degrees of adherence to dif-
ferent areas as follows: assessment and goal setting (79%), out-
come measure use’ (80%), functional mobility, strength and
balance training (93%), gait and cardiovascular training (92%),
upper limb training (52%), cognitive, somatosensory or vestibular
dysfunctions (31%) (Figure 1). Variations were shown between
domains and between different approaches. The focus of entire
physical therapy management appeared to be on the lower limb
function and mobility, as upper limb training (52%) and cognitive,
somatosensory or vestibular dysfunctions (31%) had the lowest
overall adherence with the guideline (Table 2).
This audit accentuates the facts that the domains which were
shared between interdisciplinary team had lower adherence to
the guideline than the one managed by physical therapy alone.
This is clearly visible with domains like higher brain functions and
upper limb training. This gives the impression that the physical
therapists have been concentrating much less on domains that
have been shared interdisciplinary with other professionals. This
could be due to the lack of specific guidelines outlining the duties
and responsibilities of each discipline. More precisely, the audit
identified that the physical therapist’s adherence to higher brain
functions were very low compared to the other areas. Domains
like cognitive rehabilitation, memory retraining were predomin-
antly shared by occupational and speech therapists. There were
no structured clinical practice guidelines at the time of the audit
for speech and occupational therapy for stroke rehabilitation, so
interdisciplinary comparisons of such domains were impossible at
this point.
It was also noted that physical therapists were less focused on
‘training’ leisure or social activities in the home setting as a part
of the community integration process. This needs to be discussed
further considering the duration of active inpatient stay is reduc-
ing dramatically and social integration with early support dis-
charge is getting much more attention. Overall the chart audit of
this session reveals that the physical therapists need to concen-
trate or develop strategies to contribute more on the cognitive,
somatosensory and recreational phases of rehabilitation.
The chart audit observed that the physical therapists are more
concerned with the hemiplegic shoulder pain prevention and
basic strength training than functional rehabilitation of the upper

Figure 1. Physical therapy adherence with stroke guidelines.
extremity. It may be due to the fact that in this hospital setting
upper extremity rehabilitation is mainly carried out by occupa-
tional therapists and this makes the physical therapists to give
comparatively lesser priority to the upper extremity domain than
other domains. The other reasons might be the lack of under-
standing and consensus among the teams on shared guideline
practice which was observed in all most all multi-disciplinary team
sharing domains. Low utilization of hydrotherapy became pro-
jected out as it turned into displaying the least adherence (18%)
to the usage wherein the ability is exceptionally advanced. This
need to be addressed with higher priority as the facility is highly
developed and established here. The treatments utilizing sophisti-
cated technology had also lower adherence. This was due to the
unavailability of the technologies during the chart audit period.
The guideline recommended technologies are already in place
and expected to positively influence the next phase of the
chart audit.
The audit performed by Hubbard et al [20] in an Australian set-
ting reported an adherence rate of 60% for the upper limb care.
Compared to this, the 52% adherence in the current study is justi-
fiable as the facility is using the clinical practice guideline adher-
ence practice for the first time. It must be noted that Hubbard
et al.’s data were gathered from multidisciplinary teams not just
from physical therapy alone. When physical therapists were han-
dling domains shared by other members of the interdisciplinary
team, some sort of documentation confusion leading to improper
or missing information was noted. It would be beneficial to con-
duct future researches into issues such as the influence of shared
responsibilities and team functioning in the interdisciplinary or
multidisciplinary scenario on evidence based practice and its
standardization in neurological rehabilitation. The quality depart-
ment can further focus on the development of a multidisciplinary
based stroke specialty form with the combined input from multi-
disciplinary units. At present, only the functional independence
measure instrument (FIM) form is used by multidisciplinary units
in the Cerner millennium data entry system. The quality improve-
ment division has to give more emphasis on crafting clear consen-
suses on the shared domains and each discipline, need to align it
at a higher “comprehensive rehabilitation level” to provide the
best possible and evidence based care.
PHYSICAL THERAPY ADHERENCE WITH STROKE GUIDELINES 1859
Higher quality of care and improved cost effectiveness are
important goals in guideline development, optimally resulting in
improved health [32]. The majority of the studies in this field
observed improvements in the process of care (professional prac-
tice), but with great variation across interventions [33]. The main
reasons attributable to varying degrees of adherence across differ-
ent domains may be multifactorial. Many studies have recognized
different barriers in the provision of guideline adherent care,
including but not limited to, lack of time [14,21,27,34–36], staffing
issues, team functioning, communication and prioritization of ther-
apy [25,34,37]. Other regional and hospital based factors such as
lack of guidelines, pathways and policies regarding the practice,
staff motivation, caseloads, staff mentoring and administrative pit-
falls might have their roles too. This study was meant for measur-
ing the adherence to the guidelines and didn’t analyze the factors
contributing to it. It was noted that the physical therapy after
acute stroke guideline in comparison with other guidelines has
less emphasis on areas like fatigue management, fall prevention
and management of secondary complications. The guideline
development committee can update the evidence-based practice
on these areas. But the guideline recommends usage of valid
tools for all the above mentioned areas. The management of
shoulder pain and central pain showed moderate adherence with
the guideline. The evidence to support the management of these
impairments were graded B, C or consensus, which provides less
clear direction for clinical practice.
This audit provides a comprehensive analysis of the post-stroke
physical therapy guideline adherence in an active inpatient setting
at a tertiary level hospital in Qatar, based on clinical documenta-
tion. Future research could extend this audit to find out the
guideline adherence to slow stream, long term, outpatient and
community stroke care facilities in the county and explore the fac-
tors that facilitates or hinders adherence to the stroke physical
therapy guideline. There has been a risk that a number of the
domain adherence was probably missed from reporting due to
the limitations in the Cerner documentation forms. The results
were limited by the quality of documentation, so it is not possible
to say whether patients actually received the intervention
recorded or whether they received interventions which were not
recorded. In the audit tool, any non-documented managements or
1860 M. S. AJIMSHA ET AL.

Table 2. Adherence with guideline.

Domain Session
Domain adherence (%) Sessions adherence (%)
Assessment and goal setting 79 Basic neurological measurements 73
long-term goal is ‘SMART’ 93
Short-term goals are SMART 67
Short-term goals are leading to long 90
term goals
Use of psychometric properties in 72
goal setting
Outcome measure usage 80 Recommended OM 89
Optional OM 71
Functional mobility, strength and 93 Mobilization out of bed, 55
balance training Functional Sitting balance training, 96
Standing up and sitting down training, 96
Postural control with/without visual 89
feedback in various platforms,
Functional strength training, 93
Activity-based balance training, 91
Electromyographic biofeedback for the 0
paretic leg,
Maintaining ankle dorsiflexion by means 23
of a standing frame or night splint
Hydrotherapy 18
Gait and cardiovascular training 92 Body-weight supported 46
treadmill training
Treadmill training without 94
body-weight support
Overground gait training 96
Gait training in public spaces 72
Robot-assisted gait training 0
Mobility training in virtual reality 0
Circuit class training 95
Feedback on walking speed 92
Walking aids to improve walking ability 64
Leg orthoses to improve walking ability 33
Self-propulsion in a hand-propelled 98
wheelchair
Upper limb training 52 Electrostimulation of the paretic arm 12
and hand
Mirror therapy for the paretic arm 26
and hand
(M) Constraint-induced movement 12
therapy and immobilization
VR in rehabilitation 0
Robotics in rehabilitation 0
Electromyographic biofeedback in 0
rehabilitation
Therapeutic positioning of the 70
paretic arm
Prevention or treatment of glenohumeral 68
subluxation and/or hemiplegic
shoulder pain
Bilateral arm training 61
Training muscle strength in the paretic 55
arm and hand
Circuit class training for the paretic arm 52
Cognitive and somatosensory training 31 rehabilitation for attention and mem- 13
ory deficits
rehabilitation for hemispatial neglect 31
Training of leisure/social activities in the 10
home setting
Somatosensory retraining 19
Training for dyspraxia to improve 9
ADL-independence
Vestibular Rehabilitation 36
Overall adherence 71%

domains were considered as “not adhering”. As mentioned earlier,
this study was limited to adherence of physical therapist to the
physical therapy after acute stroke guideline. A reduced adher-
ence to the guidelines therefore may also have been a result of
another profession providing the care, which was not measured
or investigated or even due to lack of specific knowledge or skill
in a specific treatment approach. This audit consequently was
unable to identify the team-based functioning of a multidisciplin-
ary team where sharing and overlap plays an enormous role. This
study thus points out the possible risk of mismanagement that
can arise from assumptions about another discipline providing an
intervention. But this can be effectively controlled at different

levels. The audit was not designed to record the effectiveness of
management; rather it was a checking for the presence of guide-
line based care in the documentation. Future observational stud-
ies will be ideal to find out such variables.
Conclusions
Clinical guidelines are systematically developed statements
designed to help practitioners and patients to make decisions
about appropriate health care. This audit provides an overall pic-
ture of the current adherence of physical therapy assessment and
management with the physical therapy after acute stroke (PAAS)
guideline at a tertiary rehabilitation hospital in the state of Qatar.
Given the evidence that implementation of clinical guidelines
leads to better quality of care and improved outcomes for
patients with Stroke, it is important to improve the adherence of
physical therapists involved in stroke rehabilitation towards rec-
ommended guidelines. An evaluation of the guideline adherence
and practice variations helps to fine tune the Physical therapy
care to a highest possible standard of practice. Proper assess-
ments of the relationship between the process of physical therapy
care and outcomes with a comprehensive set of process indicators
are highly suggested. Despite the fact that the overall adherence
of the guideline-based physical therapy practice was respectable,
some key areas might be further stepped forward, especially in
regions in which the adherence have been least however the evi-
dence are robust.
Disclosure statement
The authors report no declarations of interest
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