Stroke is a significant global health concern, standing as one of the leading causes of death and disability [1, 2]. The prevalence of stroke affects a staggering 12.2 million people worldwide, with 100 million people living with stroke sequelae [3]. The burden of it amounts to around 800 billion euros [3]. About 113,000 people in Europe experience strokes annually [1, 4]. In Catalonia, a region of Spain, approximately 11,100 people were affected by stroke in 2021, accounting for a prevalence of 2.3% [5]. Stroke survivors often experience several different motor and sensory impairments that significantly affect their mobility and independence in performing activities of daily living [6]. Motor impairments include weakness or paralysis on one side of the body (hemiparesis or hemiplegia), coordination difficulties and balance, and challenges with fine and gross motor skills [7]. Sensory impairments can also be prevalent, affecting a stroke survivor’s ability to perceive touch, temperature, and spatial awareness. All of the above underscores the immense impact of stroke, prompting extensive research across various domains, including motor rehabilitation [7], which is a crucial element of the stroke care pathway for people with persisting movement and mobility deficits [8].

According the latest actualization of the Catalan Stroke Clinical Practice Guide, in 2004, stroke was the most common cause of neurorehabilitation in Catalonia (Spain) representing 1.1 % of hospital care and 16% of home rehabilitation [9]. People with stroke begin rehabilitation during the acute phase in the hospital. After medical stabilization, they may do inpatient rehabilitation or in specialized centers. Upon returning home, they can pursue rehabilitation through ambulatory care, home care, or at a physiotherapy center [9].

A new rehabilitation plan was developed in Catalonia in 2022, which sought to guide a comprehensive approach in treating the most prevalent diseases in Catalonia, including stroke [10]. This plan recommends intervention techniques based on scientific evidence, focusing on International Classification of Functioning, Disability and Health (ICF) dimensions [10]. This recommendations contrast with earlier Catalan (2007) and Spanish (2009) guides which categorized rehabilitation techniques into compensatory, facilitation, and modern techniques [9, 11].

Nowadays, the methods and techniques employed in physiotherapy for people with stroke can vary based on practitioners’ knowledge, experience, clinical practices, and personal preferences [12]. Several studies that addressed this variability have concluded that a consensus regarding rehabilitation is necessary because there is a lack of comprehensive understanding of physiotherapists’ currents practices [13, 14, 15]. In addition, in randomized controlled trials (RCTs), researchers often compare specific techniques to conventional therapy or usual care [16]. Moreover, there exists a variety of terminology referring to this counterpart, such as usual care, the standard of care, conventional therapy, or current clinical practice, that researchers have studied and tried to define in many reviews. Still these terms are widely under described or poorly referred into a guideline, all of this implying a lack of validity, generalizability, and interpretability of results [16, 17, 18]. Hence, understanding these terms is necessary.

In stroke rehabilitation, the term “conventional” physical therapy, encompassed within the broader umbrella of “usual care”, is widely used [17]. However, there is a lack of standardization of what “conventional” includes. A recent revision found that it covers different therapies, doses, and interventions, and only a tiny percentage of the included studies justified their intervention based on clinical practice guidelines [17]. For this reason, standardized “conventional physiotherapy” is needed following current clinical guidelines to uniform the rehabilitation protocols and facilitate experimental treatment replication [17].

For these reasons, the primary objective of this study is to identify the most used physiotherapy approaches, methods, and techniques in both the public and private healthcare settings. The second objective is to explore what is the conventional physiotherapy employed in the early rehabilitation phase, the late rehabilitation phase, and rehabilitation in chronic phase [19] stroke survivors in Catalonia.

A total of 118 physiotherapists from Catalonia (87 women, 30 men, one no binary), aged between 21 and 65, with professional experience in neurorehabilitation ranging from one to more than ten years in different settings (public or private sector) and from various regions of Catalonia (Lleida, Tarragona, Barcelona, and Girona), answered the survey (Table 1).

3.1 Therapeutic Intervention

We classified the responses as related to the therapeutic intervention at different points.

3.1.1 Descriptive Analysis of the Use of Physiotherapy Techniques

The respondents qualified the different approaches using of frequencies (always, very frequently, occasionally, rarely, and never). Among the classic techniques included, the most used was passive mobilization, with 14.4% of the participants indicating they always used it, and 36% using it very frequently, while electrotherapy was the least utilized (58% never used it) (Fig. 1).

Fig. 1.

This graph shows the distribution of participants’ responses based on the techniques they utilized in stroke rehabilitation. CIMT, constraint-induced movement therapy; ICTs, information and communication technologies.

Regarding exercise, balance training was the most used, followed by strength exercises; treadmill and bicycle training were the most minor (5.90% never use it). About specific neurological techniques, the task-oriented approach was the most used; on the other hand, the constraint-induced movement therapy (CIMT) was the least used technique (55.90%) never used it. The respondents did not generally use advanced technologies or other techniques such as music therapy or mindfulness in physiotherapy stroke rehabilitation in Catalonia.

3.1.2 Descriptive Analysis of the Method Approaches in Physiotherapy

Participants were asked: “During the rehabilitation of people with stroke, do you follow any of these specific approach methods? (non-specific approach, Basale stimulation (BS), neurocognitive therapy, neurodevelopment therapy and Proprioceptive Neuromuscular Facilitation (PNF))”. The chosen approach should represent the primary focus of your clinical practice. The results showed that 57.60% of the subjects indicated that they do not adhere to a specific method; instead, they employ various approaches depending on the patient or the stage of the stroke, often using a combination of methods (Table 2).

Table 2. Frequencies of the different methods used in stroke rehabilitation.

Methods	Frequency	Percentage
Non-Specific method	68	57.60%
Basale Stimulation	15	12.70%
Neurocognitive therapy	14	11.90%
Neurodevelopmental therapy	11	9.30%
PNF	10	8.50%
Total	118	100.00%

PNF, Proprioceptive Neuromuscular Facilitation.

Descriptive analysis of the specific and non-specific approaches with post stroke phases, settings, and years of experience. Coded variables and Description of the frequencies.

There were no significant differences between phases regarding the utilization of a specific approach or not ($\chi$² = 0.53; p-value = 0.76). Additionally, no significant differences were found in utilizing specific or non-specific approaches in public and private settings ($\chi$² = 2.82; p-value = 0.24). Similarly, no differences were observed between years of experience and the approaches they employ ($\chi$² = 0.81; p-value = 0.66).

There was no association between stroke stages and the methodological approach used, as most respondents did not employ a specific method. However, during the subacute and chronic phases following a stroke, BS and neurocognitive therapy appear to be the second most used approaches.

Similarly, there was no association between public or private settings and the methodological approach used. Both settings predominantly do not employ a specific method. However, in private settings, BS, neurocognitive therapy, and neurodevelopment therapy were more frequently utilized compared to public settings. In contrast, PNF was more used in public than in private settings.

Most respondents indicated that they did not employ a specific method regardless of their years of experience. However, respondents with over ten years of experience tended to utilize BS, neurocognitive therapy, neurodevelopmental therapy, and PNF more frequently. Conversely, respondents with 0 to 2 years of experience tended to use neurodevelopmental therapy and PNF (Table 3).

Table 3. Frequencies of associations between the method and poststroke phases, work setting and years of experience of the physiotherapists.

		Non-Specific method	Basale Stimulation	Neurocognitive therapy	Neurodevelopment therapy	PNF	Total
Phases poststroke
	Acute	0	1	0	1	1	3
	Acute/Subacute	4	0	0	2	1	7
	Subacute	16	0	1	3	2	22
	Subacute/Chronic	23	10	7	3	5	48
	Chronic	15	4	4	2	1	26
	Acute/Subacute/Chronic	10	0	2	0	0	12
	Total	68	15	14	11	10	118
Years of experience
	0–2 years	12	0	2	3	4	21
	3–5 years	19	5	2	2	1	29
	6–9 years	11	3	1	2	2	19
	$>$10 years	26	7	9	4	3	49
	Total	68	15	14	11	10	118
Work Setting
	Public	24	1	3	2	5	35
	Private	31	9	9	5	2	56
	Both	13	5	2	4	3	27
	Total	68	15	14	11	10	118

3.1.3 Describing Conventional Physiotherapy Across Open Question

In the open question, participants were asked, “In your opinion, what do you consider as conventional therapy for people who have suffered a stroke?”. The survey findings indicated that several respondents were unsure of what conventional physiotherapy includes. However, most respondents agreed that it includes passive mobilizations, stretching, strength exercise, balance, and gait training. Other therapies mentioned included methods such as Bobath, Votja, and PNF (Fig. 2).

Fig. 2.

Word cloud generated from responses to the open-ended question ‘What is conventional physiotherapy?’. The size of each word corresponds to its frequency

To the best of our knowledge, this is the first study that pretends to know what conventional physiotherapy within stroke rehabilitation includes, specifically in the context of Catalonia, Spain. The term “conventional physiotherapy” currently lacks standardization, rendering it challenging to discern the specific methods and approaches this broad category encompasses. In the study, the mission of physiotherapists who participated in the survey was to identify and categorize their rehabilitation practices in people with stroke.

Regarding the use of classic physiotherapy techniques, passive mobilization emerges as the most used in stroke rehabilitation in Catalonia, followed closely by stretching. Balance and strength exercises take precedence in exercise techniques, followed by therapeutic physical exercise. Within neurologically specific techniques, the task-oriented approach claims the top spot, trailed by bimanual therapy, motor imagery, mirror therapy, and intensive therapy. On the contrary, CIMT ranks as the least utilized approach. These findings align with Arienti et al.’s 2022 study [17], noting the underutilization of CIMT despite the evidence supporting its efficacy compared to other rehabilitation approaches on the recovery from motor impairment and motor function but not in disability. Physiotherapists may not employ this technique probably because of the specific type and intensity of exercise required and patient inclusion criteria, requiring some degrees of active extension in the wrist and fingers, minimal pain or spasticity, and a high level of compliance with the rehabilitation treatment [22].

According to our study, physiotherapists in Catalonia rarely used advanced technologies (such as virtual reality) despite the extensive growing evidence of their use [14]. In our view, the lack of investment in advanced technologies in public settings stems from a reticence to invest in costly rehabilitation equipment designed for individual use. Other techniques, such as music therapy or mindfulness, are not widely used, possibly due to the need for more evidence and results from these interventions [23, 24] or the lack of training in these disciplines among physiotherapists.

Concerning the analysis of the method approaches in conventional physiotherapy, our results showed that physiotherapists agreed they do not use a specific method during their interventions, as corroborated by a new revision [17]. Therefore, our results have shown the downward usage trends observed in recent years and manifest the change in the therapeutic approach to manage people with stroke [25, 26], due to most of the Catalan physiotherapists have already left behind the exclusive use of classic methods such as the Bobath, Brunnström, Rood method and PNF [26], following the recommendations of the new clinical practice guidelines [10, 19].

Our results showed that BS, neurocognitive therapy, and neurodevelopment therapy are more used in private settings than in public ones. In our opinion, this greater presence may be partly because private centers operate for business reasons, following a more specific approach or methodology, differentiating themselves from the others. Furthermore, private centers have the time necessary to develop these techniques. On the other hand, in public settings, as mentioned, they may follow the guidelines of the clinical practice guides, so they have more flexibility when using one technique or another. Another possible explanation for the lack of a specific method in the public setting is the limited time available per patient, influenced by the institution’s organization and the shortage of human resources. There significant differences between public and private settings regarding the time allocated per session for a patient. Physiotherapists in private settings typically spend one hour or more with each patient; the Spanish Neurorehabilitation Society Clinical Practice Guide [27] recommends a minimum of 45 minutes, five days a week. In contrast, those working in the public sector generally allocate between 15 and 45 minutes per stroke patient. Moreover, they often conduct more group sessions than individual sessions.

When examining the various stages of stroke and the approaches employed, our results showed a notable absence of substantial differences, consistent with the systematic review conducted by Arienti et al. in 2022 [17]. In contrast, the differences depend on whether they go to a private or public setting. In Catalonia, people with chronic stroke do not usually go to public settings to continue their rehabilitation; they only undergo routine checks in Primary Care. To continue their treatment, usually they are typically obligated to seek services at a private center [28].

One limitation of this study is the data collection instrument. Since no previous studies explored the proposed objective, a questionnaire was developed by experts in neurological physiotherapy. However, it exhibits certain methodological biases inherent to its design. Although the questionnaire underwent a pilot test, it is not a validated or standardized assessment tool. As a result, variations in participants’ interpretations may have occurred, particularly in the section addressing therapeutic approaches and techniques. Another limitation of the study is the response bias, as we do not have a real number of the active neurological physiotherapy community in Catalonia to compare with; therefore, the response rate percentage is unknown.

The study concludes that physiotherapists in Catalonia generally do not rely on a specific method or technique; instead, they use a combination of them. However, the three most used techniques or approaches are the task-oriented approach, balance training and strength training. Conversely, the three least (or never) used techniques are acupuncture, meditation, and dry needling. In regard to participants’ opinions on what conventional physiotherapy is, the three more linked concepts were passive mobilizations, stretching and strength exercise.

Consequently, we cannot definitively conclude what conventional physiotherapy includes due to the heterogeneity of answers collected in this survey and the huge variety of existing techniques and approaches. Due to this uncertainty, it is advisable to explicitly state the techniques and methods that encompass conventional physical therapy in all scientific studies of this nature.

The datasets generated during the current study are available from the first author on reasonable request.

MMA, SPH, HFL, SGH, CS, and RCV designed the research study. MMA and SPH performed the research. RCV, CS, SGH provided help and advice on questionnaire design. HFL and MMA analyzed the data. MMA, SPH and HFL wrote the manuscript. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

This study followed the principles of the Declaration of Helsinki 2023 and the Belmont Report. The Research and Transfer Ethics Committee (CERT) of the University of Lleida (CERT-UdL) approved the study (reference number CERT09). The researchers explained the purpose of the study to the participants and obtained written informed consent from each participant before starting the survey. Participation was anonymous, and each participant was assigned a code. The entire process was carried out considering the Organic Law on data protection: 3/2018, December 5, on the Protection of Personal Data and Guarantee of Digital Rights (LOPD-GDD). An inclusive gender approach, considering intersecting social categories like ethnicity, age, or disability, was adopted for citizen benefit.

This research received no external funding.

The authors declare no conflict of interest.

Supplementary material associated with this article can be found, in the online version, at https://doi.org/10.31083/RN37316.