Review author Ibrahim Npochinto Moumeni describes the work as a narrative review prepared with recommendations from SANRA, using purposive searches of PubMed, Scopus and Google Scholar. The initial search covered January 2019 to December 2022 and was updated to December 2025 to capture later publications reporting data collected during 2020 and 2021. Sources included systematic reviews, large multicentre studies, official agency reports and selected French research. The 49-source evidence base was selected thematically rather than through a systematic screening process, and individual studies did not receive formal quality appraisal. First-person observations from the author’s postgraduate training in two French university hospitals were kept separate from the literature and were not used to support quantitative claims.

Health-worker mortality was one of the review’s central subjects. WHO estimated that between January 2020 and May 2021, 80,000 to 180,000 health and care workers died from COVID-19, with a central estimate of 115,500. Over the same period, 6,643 health-worker deaths had been reported through surveillance, less than 6% of the central estimate. Early systematic-review data through 8 May 2020 identified 152,888 infections and 1,413 deaths among health workers. Infections were concentrated among women, who represented 71.6% of cases, and nurses, who accounted for 38.6%; deaths were concentrated among men, who represented 70.8% of fatalities, and physicians, who accounted for 51.4%. In the United Kingdom and United States, front-line workers had an adjusted 3.4-fold higher risk of a positive test than the general community, with risk increasing further where protective equipment was inadequate or reused.

Although the United States did not produce an official national count, an investigative journalism database documented more than 3,600 health-worker deaths during the first pandemic year and found that lower-paid staff, including nurses and support workers, were disproportionately represented. The review also reports psychological distress among health workers, citing a meta-analysis with pooled prevalences of 23.2% for anxiety, 22.8% for depression and 38.9% for insomnia. From the synthesis and the author’s clinical observations, the paper proposes Frontline Abandonment Syndrome as a possible description of temporary or prolonged withdrawal from high-risk duties and its consequences for continuity of care. This is a hypothesis rather than a diagnosis or validated syndrome; it differs from burnout, moral injury and compassion fatigue by focusing on observable withdrawal and organisational conditions such as protective-equipment availability and communication.

Vaccine hesitancy was another major focus. Defined in the review as delay in accepting or refusing vaccination despite its availability, hesitancy was reported in 37% of 4,630 health workers surveyed across 91 countries between February and April 2021. A separate review involving 76,471 workers estimated hesitancy at 22.5%, while a scoping review of 41,098 nurses in 36 countries found a pooled refusal prevalence of 20.7%. The nurse review found refusal prevalence was higher in 2020 than in 2021. Reported reasons included safety concerns, side effects, doubts about efficacy, misinformation and mistrust of authorities or pharmaceutical companies. The figures cannot be compared directly because the studies used different populations, periods and definitions, and the review notes this limitation explicitly.

French data showed an occupational gradient at the beginning of the vaccination campaign. In a February 2021 survey of 1,965 workers at a tertiary centre, 73.1% favoured vaccination, 23.1% were hesitant and 3.9% opposed it. Fewer than 60% of auxiliary nurses and technicians intended to be vaccinated, compared with 60% to 79% of nurses and support staff and more than 80% of medical personnel. Controversy surrounding AstraZeneca tolerability was independently associated with lower vaccination intention. The review also discusses the temporary European pause involving France in March 2021 and the legal requirement introduced in France on 5 August 2021. From these observations, the author proposes the Vaccination Refusal Cascade, a hypothesis in which a salient institutional or media event triggers successive refusals across professional networks. The French association is consistent with that idea but does not demonstrate that such a cascade occurred.

Physiotherapy guidance developed during the pandemic addressed respiratory management, patient positioning, early mobilisation and exercise prescription under strict infection-control conditions. A Stanford Hall consensus described post-discharge rehabilitation, including a graded return to activity, while a rapid living systematic review documented the emerging evidence on patients’ rehabilitation needs. A WHO pulse survey also recorded widespread disruption of essential health services, including rehabilitation, in 2020. The author’s clinical observations from home-based physiotherapy during the first French lockdown described programmes adapted to minimal equipment, greater family involvement and the integration of psychosocial support. These observations illustrate practical adaptations but do not constitute evaluated outcomes, and they come from a single practitioner in a high-resource setting.

For patients with persistent symptoms, the review distinguishes physiological recovery from functional recovery. WHO defines post-COVID-19 condition as symptoms that usually arise three months after probable or confirmed infection, continue for at least two months and cannot be explained by another diagnosis; fatigue, post-exertional symptom exacerbation, cognitive dysfunction and dysautonomia are frequent. The proposed Post-COVID Functional Decoupling describes a pattern in which measures such as oxygenation, imaging and inflammatory markers normalise while functional capacity lags by weeks or months. It is not presented as a diagnosis, but as a rehabilitation-oriented pattern within post-COVID-19 condition and post-intensive care syndrome. The stated practical implication is that functional measures may guide rehabilitation and discharge decisions, while exercise progression must be individualised because post-exertional symptom exacerbation can occur.

The shift to remote rehabilitation produced both promising evidence and limited routine uptake. A rapid overview found telerehabilitation generally comparable to in-person physical therapy for several conditions. A Cochrane review of 15 studies involving 1,904 participants, mostly patients with chronic obstructive pulmonary disease, found pulmonary telerehabilitation achieved outcomes similar to centre-based rehabilitation without reported safety issues, although certainty of evidence was limited. A retrospective study of 164 patients found telerehabilitation non-inferior to in-person rehabilitation 12 weeks after total knee arthroplasty, and a prospective observational study of 23 patients found mixed in-person and remote delivery feasible in cancer rehabilitation. Yet a US database containing 222,680 outpatient physiotherapy episodes recorded telerehabilitation in only 6% of cases, declining from 10% to 5% between the second and third quarters of 2020. The proposed Telerehabilitation Emergency Pivot describes the rapid, improvised system-level transition to remote care and the subsequent persistence of hybrid models.

The review’s four constructs collectively shift attention toward service-level processes: from psychological distress to observable workforce withdrawal, from generic hesitancy to possible network diffusion, from digital transition to rehabilitation-specific constraints, and from physiological normalisation to delayed functional recovery. Proposed tests include linking staffing and deployment data with protective-equipment availability and validated distress measures; interrupted time-series analyses around vaccine safety alerts; adoption and safety comparisons across in-person, remote and hybrid rehabilitation; and cohort studies comparing physiological recovery with functional measures such as the six-minute walk test and activities-of-daily-living scales. These ideas remain hypotheses. The evidence base is non-exhaustive and exposed to selection and publication bias, clinical observations are vulnerable to recall bias, rehabilitation data from sub-Saharan Africa are scarce, and the review focuses mainly on 2020 and 2021. Formal concept analysis and empirical testing are therefore required before the proposed terms should be used beyond research settings.

Subject of Research: Narrative review of health-worker mortality, vaccine hesitancy, physiotherapy and telerehabilitation during COVID-19

Article Title: Rehabilitation professionals at the COVID-19 frontline: a testimony-informed narrative review of health-worker mortality, vaccine hesitancy, physiotherapy and telerehabilitation

Article References: Npochinto Moumeni, I. (2026). Rehabilitation professionals at the COVID-19 frontline: a testimony-informed narrative review of health-worker mortality, vaccine hesitancy, physiotherapy and telerehabilitation. Frontiers in Rehabilitation Sciences, 7, Article 1921614. https://doi.org/10.3389/fresc.2026.1921614

Image Credits: AI Generated

DOI: 10.3389/fresc.2026.1921614

Keywords: COVID-19, health workers, mortality, vaccine hesitancy, physiotherapy, telerehabilitation, post-COVID condition, rehabilitation services, narrative review, pandemic preparedness, Rehabilitation, professionals

The study included 168 registered physiotherapist participants in Saudi Arabia, recruited through purposive and snowball sampling. Most participants were aged 18–24 years (54.2%), and 73.8% were female. Researchers administered an online questionnaire containing 20 Likert-scale items drawn from validated Technology Acceptance Model subscales covering perceived usefulness, perceived ease of use, knowledge retention and clinical decision-making. The reported Cronbach’s alpha values were at least 0.80, indicating strong internal consistency for the questionnaire measures.

Data were analyzed using descriptive statistics, independent t-tests, one-way analysis of variance and Pearson correlation coefficients, with p < 0.05 used as the significance threshold. Participants reported highly positive perceptions across all four domains. Prior micro-learning use and greater technical proficiency were each associated with more favorable perceptions at p < 0.001, with reported Cohen’s d values ranging from 0.50 to 0.90. A dose–response relationship was also observed between increased exposure to micro-learning and the reported perceptions.

Associations among the measured constructs ranged from r = 0.622 to r = 0.779, all reported at p < 0.0001. Perceived knowledge retention and perceived clinical decision-making were strongly correlated, with r = 0.760. The range across all reported correlations reached r = 0.779, so the knowledge-retention and clinical-decision-making result should be understood as one of the strong associations rather than the single largest correlation reported in the abstract.

The abstract concludes that physiotherapists perceive micro-learning as a practical and effective approach for professional development, with prior exposure and technical proficiency identified as key predictors of acceptance. However, the evidence comes from a cross-sectional online survey in one country using non-random recruitment. Perceptions of knowledge retention and clinical decision-making are not equivalent to objectively measured learning gains or changes in clinical decisions, and the design cannot establish that micro-learning caused the reported associations. The published version is also described as an early version of record that may undergo further editorial changes.

Subject of Research: Physiotherapists’ perceptions of micro-learning for professional development in Saudi Arabia

Article Title: Perceptions of micro-learning modules on knowledge retention and clinical decision-making among physiotherapists: a cross-sectional study

Article References: Shalabi, K. M., Alsharif, Z. A., Almubarak, K. M., Almalki, R. A., Almathami, S. H., Alhakami, B. A., & Almurdi, M. M. (2026). Perceptions of micro-learning modules on knowledge retention and clinical decision-making among physiotherapists: a cross-sectional study. BMC Medical Education. https://doi.org/10.1186/s12909-026-10485-3

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10485-3

Keywords: micro-learning, physiotherapy, Saudi Arabia, cross-sectional survey, knowledge retention, clinical decision-making, Technology Acceptance Model, continuing professional development, Perceptions, modules, knowledge, retention

Physiotherapists were invited to share their experiences and perspectives on microlearning through open-ended survey questions. Researchers analyzed the responses using reflexive thematic analysis with an inductive approach to identify patterns of meaning. The study examined perceived barriers and facilitators, as well as participants’ views about knowledge retention and clinical decision-making; it did not measure objective learning outcomes or establish the effects of microlearning on clinical performance.

Reported barriers included time constraints, workload pressures, concerns about content quality and limited clinical specificity. Participants identified integration into clinical workflows, ease of access and organizational support as facilitators. Case-based learning, visual content and interactive elements were described as important features for enhancing knowledge retention. The abstract reports that physiotherapists perceived microlearning as a form of just-in-time cognitive support that could support rapid recall of clinical information and decision-making at the point of care.

Engagement with credible and contextually relevant content was associated with increased confidence and perceived improvements in patient safety. These are perceptions reported by participants rather than demonstrated improvements in safety or patient outcomes. The authors state that longitudinal and mixed-methods studies should examine microlearning’s integration into physiotherapy education and its impact on knowledge retention, clinical decision-making and practice. Because the supplied evidence is limited to the article abstract, details about participant numbers, recruitment, setting and the full survey instrument are not available here.

Subject of Research: Physiotherapists’ perceived barriers, facilitators and clinical implications of microlearning

Article Title: Microlearning in physiotherapy practice: a qualitative study on barriers, facilitators, and implications for knowledge retention and clinical decision-making

Article References: Shalabi, K., Alsharif, Z., Almubarak, K., Almalki, R., Almathami, S., Alhakami, B., Almurdi, M., & Albasha, N. (2026). Microlearning in physiotherapy practice: a qualitative study on barriers, facilitators, and implications for knowledge retention and clinical decision-making. BMC Medical Education. https://doi.org/10.1186/s12909-026-10488-0

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10488-0

Keywords: microlearning, physiotherapy, continuing professional development, qualitative study, knowledge retention, clinical decision-making, patient safety, thematic analysis, practice, qualitative, barriers, facilitators

The stakes of the question are high. Exercise-based rehabilitation is recommended as part of best-practice cancer care because regular physical activity can blunt the adverse effects of treatment, improve physical and psychological function, and enhance quality of life. Large-scale evidence cited by the researchers suggests that long-term exercise improves disease-free survival by 28 percent and overall survival by 37 percent in people with cancer. Yet survivors entering rehabilitation are typically far below recommended activity levels: previous studies report an average of just 12 minutes of moderate-to-vigorous activity per day, and half say they exercise fewer than two days a week.

Structured, supervised rehabilitation programs are seen as a promising first step toward changing those numbers, but keeping people active once the program finishes has proven difficult. Telerehabilitation — delivered through videoconferencing, wearable devices, and mobile applications — was developed to overcome practical barriers to attending in-person sessions, allowing participants to exercise safely at home while still receiving demonstration, instruction, monitoring, and expert guidance. Group-based cancer exercise telerehabilitation has been shown to be safe and feasible, although earlier work raised concerns that participants may find it harder to build the social connections that make in-person groups motivating.

In the TeleCaRe trial, participants in the experimental arm received an eight-week program of twice-weekly, 60-minute group exercise sessions supervised by a physiotherapist trained in cancer care. The sessions combined seated or standing aerobics, body-weight exercises such as squats, and equipment including resistance bands and free weights, all individually tailored. The program also incorporated information provision, self-monitoring through a Fitbit activity tracker, feedback, goal setting, an online information portal, and an individualized home exercise plan — a package of recognized behavior change techniques. Before starting, and again at discharge, participants discussed ongoing exercise options one on one with the physiotherapist.

To understand the medium-term impact, the researchers purposively sampled 17 trial participants — roughly half female, averaging 58 years old, with ages ranging from 21 to 80 — for semistructured interviews four months after their final session. Interviews were conducted by PhD-qualified physiotherapists not involved in delivering the program, audio-recorded, transcribed verbatim, and independently coded by two researchers using NVivo software. The team analyzed the data inductively within an interpretive description framework, refining a shared codebook through repeated discussion, and returned transcripts to participants to verify accuracy. Data collection ran from June 2022 to December 2023 across a large public health service spanning metropolitan Melbourne to regional Victoria.

The overarching theme that emerged was that telerehabilitation facilitated positive exercise intentions that persisted well beyond the program. Participants described the program as a lifeline that connected them with skilled, empathetic clinicians at a dark point in their recovery, empowering them through knowledge, opportunity, and connection. One participant with breast cancer recalled being weak, having lost her hair, and feeling awful, saying the program pulled her out of that period and calling such services a lifeline for people like her. Others articulated vivid long-term reasons for exercising, from coping better with chemotherapy to reducing the fear of recurrence.

For many, feeling the benefits of exercise during the program — less fatigue, a return to work — created a positive cycle that prompted them to seek further activity once it ended. Some returned to the gym, took up golf, lawn bowls, or swimming, or folded the program’s home exercises into their regular routines. Purposeful walking was the most common activity because it was convenient. Family members reinforced the momentum, sometimes exercising alongside participants or buying them equipment, and for some the program acted as a conduit back into community life, such as volunteering at a bowls club.

But acting on those intentions proved far harder in what participants called the new reality created by cancer. Comorbidities, ongoing treatment side effects such as pain and fatigue, and disrupted life circumstances limited many people’s ability to exercise, and some expressed guilt about not keeping up. Without the structure, accountability, and convenience of scheduled sessions, several described a disconnect between knowing they should exercise and actually doing so. COVID-19 added a double barrier: some participants contracted the infection and were physically unable to exercise, while others avoided community gyms and pools for fear of infection due to immunocompromise.

Previous exercise experience emerged as the strongest determinant of who kept moving. Survivors who had exercised before their diagnosis — swimming, running, gym training, regular walking — described those activities as goals to return to and appeared to bounce back quickly from setbacks, likely helped by higher self-efficacy. Those new to exercise held positive intentions but were less likely to act on them, often managing only incidental activity around the home or occasional walks. The researchers suggest this pattern fits the transtheoretical model of behavior change: telerehabilitation helps people move from contemplation into action, but the leap from action to maintenance is difficult once professional supervision disappears, and health setbacks can push people back toward contemplation even as their positive intent remains.

The authors conclude that telerehabilitation can be a valuable first step toward initiating exercise, but that many survivors — particularly those without previous exercise experience — need ongoing support afterward to convert good intentions into sustained behavior. In real-world clinical settings, resources rarely allow the years-long, phased support used in the landmark trial linking exercise to improved colon cancer survival, so the researchers point to flexible models such as physiotherapy navigators and community-based programs like LiveStrong at the YMCA or the Alberta Exercise Program to bridge the gap. The study has limitations: participants came from a motivated trial cohort who needed internet access, adherence to the program was low, and interviews were short, though no new themes emerged in the final transcripts. Even so, the message is clear — the webcam sessions plant the seed, but the hard work of keeping cancer survivors exercising begins when the screen goes dark.

Subject of Research: Cancer survivors' exercise behaviour after completing a group exercise telerehabilitation program

Article Title: A qualitative study of cancer survivors’ exercise behaviour 4 months after a telerehabilitation program

Article References: Dennett, A. M., Peiris, C. L., Rimayanti, M. U., Barton, C., Taylor, N. F., Harding, K. E., Tan, G., Ezzat, A., & Shields, N. (2026). A qualitative study of cancer survivors’ exercise behaviour 4 months after a telerehabilitation program. Supportive Care in Cancer, 34(10), Article 941. https://doi.org/10.1007/s00520-026-11016-y

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11016-y

Keywords: telerehabilitation, cancer survivors, exercise, behavior change, qualitative research, physiotherapy, cancer rehabilitation, telehealth, physical activity, survivorship, qualitative, cancer

The case centers on a previously healthy infant who required seven days of invasive mechanical ventilation after the viral infection progressed to pneumonia. Once the breathing tube was removed and the child was switched to high-flow nasal cannula support, clinicians expected gradual improvement. It did not come. The infant showed persistent, moderate-to-severe increased work of breathing and needed six days of noninvasive ventilation. And when the positive pressure support was finally withdrawn, a new and puzzling set of signs emerged: a progressive pectus excavatum, the sunken chest deformity, along with retractions beneath and between the ribs, a protuberant abdomen, reduced lung expansion on chest radiography, and axial hypotonia.

To understand what happened, it helps to consider how the diaphragm works. This dome-shaped muscle separates the chest from the abdomen and performs roughly the majority of the work of quiet breathing. When it contracts, it flattens and descends, drawing air into the lungs and pushing abdominal contents downward. In newborns and young infants, the rib cage is unusually compliant, meaning the mechanical load on the diaphragm is high and the muscle must work harder to move the chest wall. Infants are therefore especially vulnerable when the diaphragm weakens, and the outward signs can mimic other problems, including airway obstruction, residual lung disease, or even a structural chest deformity.

That vulnerability is compounded by modern intensive care. Invasive mechanical ventilation, while lifesaving, can itself injure the diaphragm. Prolonged inactivity of the muscle, deep sedation that reduces spontaneous breathing effort, and systemic inflammation all contribute to what researchers call ventilator-induced diaphragmatic dysfunction. In infants, whose respiratory muscles are already biomechanically immature, the effect can be pronounced. The challenge for clinicians is that the resulting weakness is invisible on standard monitoring. Oxygen levels and carbon dioxide readings reflect the outcome of breathing, not the strength of the muscle doing the work.

This is where diaphragmatic ultrasonography has changed the game. Using a standard ultrasound probe placed on the chest wall or upper abdomen, clinicians can measure the thickness of the diaphragm at end-expiration and at peak inspiration, and calculate a diaphragmatic thickening fraction, the percentage increase in thickness during contraction. In this infant, the initial ultrasound revealed a diaphragm only 1.35 millimeters thick at rest, thickening by just 17 percent during inspiration. Both figures pointed clearly to diaphragmatic weakness rather than an inspiratory overload problem, a distinction that would prove decisive for treatment.

Armed with that objective measurement, the team made a choice that could easily have gone the other way. Rather than reintroducing positive pressure support, which might have further unloaded and weakened the muscle, they kept the infant on high-flow nasal cannula and launched an individualized physiotherapy program. The plan included sensorimotor stimulation to reactivate breathing patterns, abdominal muscle strengthening exercises, and an abdominal support band to stabilize the trunk and improve the mechanical efficiency of the diaphragm. The approach treated the diaphragm like any other deconditioned muscle: it needed graded, targeted exercise, not rest.

Seventy-two hours later, repeat ultrasound told a different story. The diaphragmatic thickening fraction had nearly doubled to 33 percent, and inspiratory thickness had risen to 1.60 millimeters. Alongside those numbers came visible clinical change: better coordination between chest and abdominal movement during breathing, regression of the sunken chest deformity, and improved lung aeration. The high-flow support was subsequently discontinued, and the infant was discharged with clinical improvement. The transient pectus excavatum, which had appeared as the diaphragm failed to generate the pressures needed to stabilize the compliant infant rib cage, resolved as the muscle recovered.

The authors of the report, a multidisciplinary team from Rios D’or Hospital and the Fernandes Figueira National Institute of Women’s, Children’s and Adolescents’ Health at Fiocruz in Rio de Janeiro, argue that the case illustrates three distinct contributions of bedside ultrasound in pediatric critical care. First, it enabled early identification of diaphragmatic dysfunction before the infant deteriorated further. Second, it allowed the team to differentiate weakness from inspiratory overload, two conditions that can look identical at the bedside but demand opposite treatments. Third, serial measurements helped avoid the unnecessary reintroduction of positive pressure support, which could have prolonged the very problem it appeared to solve.

The implications extend beyond a single patient. Diaphragmatic ultrasound is noninvasive, radiation-free, repeatable at the bedside, and increasingly validated in adult critical care, where thickening fraction thresholds are used to predict weaning outcomes. Its adoption in pediatrics has been slower, partly because normal values in infants are less established and because the technique requires training. But cases like this one suggest a practical pathway: instead of guessing whether a struggling infant after extubation has residual lung disease, airway issues, or muscle weakness, clinicians can measure the muscle directly and tailor rehabilitation accordingly. Serial assessments could also serve as an objective endpoint for physiotherapy programs, replacing subjective impressions with numbers that track recovery.

For now, the case stands as a vivid example of precision in pediatric intensive care, where a handheld probe and a few millimeters of muscle thickness changed the course of treatment. The infant’s diaphragm, weakened by a week of mechanical ventilation and immaturity of the respiratory system, rebounded within days once it was given the right support and the right exercises. The chest deformity vanished, the breathing pattern normalized, and the child went home. As more intensive care units adopt diaphragmatic ultrasonography as a routine monitoring tool, stories like this may shift from remarkable exceptions to expected standards of care, offering a way to see the invisible work of the body’s most important breathing muscle and to help it recover before small problems become large ones.

Subject of Research: Ultrasound-guided diagnosis and rehabilitation of ventilator-induced diaphragmatic dysfunction in an infant

Article Title: Ultrasound-guided management of reversible diaphragmatic dysfunction after extubation in an infant with transient pectus excavatum: a case report

Article References: da Silva, C. D. A., Valentim, M., Terra, M. A., da Fonseca Borges, A., de Pinho Silveira, D. A., Fernandes, P. V., Moore, D. C. B. C., & dos Santos Gomes Junior, S. C. (2026). Ultrasound-guided management of reversible diaphragmatic dysfunction after extubation in an infant with transient pectus excavatum: a case report. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07610-y

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07610-y

Keywords: diaphragmatic dysfunction, ultrasonography, mechanical ventilation, infants, pectus excavatum, respiratory muscles, physiotherapy, pediatric intensive care, ventilator weaning, RSV bronchiolitis, Ultrasound-guided, management

The research team, led by Nicholas B. Washmuth of Samford University and The University of Alabama in Huntsville, together with colleagues from clinics in the United States, the United Kingdom, and Canada, set out to answer a question that has rarely been tested with real patients: when a clinician swears, do patients actually care? Swearing is a nearly universal feature of human communication, with surveys showing that 58 percent of people report swearing sometimes or often, over 70 percent of adults frequently or occasionally hear others swear in public, and 57 percent of employees acknowledge swearing in the workplace. Yet in healthcare, the impact of clinician swearing on patients has remained unclear, with limited evidence pointing in conflicting directions.

Earlier studies offered mixed signals. In one set of experiments on physician communication, patients rated doctors who swore lower in satisfaction, expertise, trustworthiness, and approachability, yet the same patients also perceived the swearing physicians as more human and relatable, and many said they would still choose to see that doctor again. In mental health settings, a survey of 50 patients whose therapists had used swear words found overwhelmingly positive responses: 92 percent said therapists should be able to swear around their clients, 80 percent reported that the swearing helped their therapeutic relationship, and over 88 percent described an explicitly positive experience. Case reports in physical therapy showed similarly mixed but generally acceptable patient reactions, with neither patient in the cases finding the swearing offensive or unprofessional.

To build on this sparse evidence, the team conducted a cross-sectional, mixed methods, retrospective study with 57 physical rehabilitation patients, 34 females and 23 males, with a mean age of 40.39 years. Patients were recruited from two physical therapy clinics in Alabama and one chiropractic clinic in Ontario, Canada, over a 10-month period from August 2024 to May 2025. Each patient completed an anonymous 14-item survey on the day of discharge, a timing choice designed to ensure accurate recollections and reduce social desirability bias, since patients were no longer receiving care and had nothing to gain from flattering their clinicians. The survey assessed experiences, perceptions, and attitudes toward clinician swearing, and the full instrument and dataset are available in an Open Science Framework repository.

The quantitative results were striking. Thirty-one patients, or 54.39 percent, reported that their clinician used swear words during their sessions, and among those who swore, 61.29 percent did so more than once per visit. Among the 31 patients who experienced clinician swearing, 61.13 percent said it increased their motivation, 58.06 percent reported improved self-confidence, and 51.61 percent said it supported their adherence to treatment. No patient reported that swearing decreased any of these outcomes. Furthermore, 54.84 percent agreed or strongly agreed that the swearing was patient-centered, and 64.52 percent said it improved their rehabilitation experience, while 80.65 percent disagreed or strongly disagreed that it was unprofessional and 96.77 percent disagreed or strongly disagreed that they were offended.

The researchers also tested whether swearing frequency, dichotomized into high, more than once per session, versus low, once per session or less, predicted patient outcomes using logistic and linear regressions. Patients in the high-frequency group generally reported greater motivation, self-confidence, and adherence than those in the low-frequency group, but the confidence intervals for these effects were wide and included null values, reflecting the small sample size and limited statistical power. The only statistically significant finding was that high-frequency swearing was associated with higher ratings of patient-centeredness, B = −1.00, 95% CI (−1.95, −0.05), p = 0.04, though the authors emphasize that even this confidence interval spans a wide range. Because the study was exploratory and underpowered, the team deliberately emphasized descriptive statistics and confidence intervals over p-values, noting that hypothesis testing with p-values can be unreliable in underpowered studies.

The qualitative side of the study used cognitive network analyses, processing patients’ open-ended responses into single-word terms and building networks that depicted important concepts and their associations. When asked when it is appropriate for a clinician to swear, patients focused on the impact on the therapeutic relationship. Swearing was judged acceptable when it served to motivate, encourage, or affirm progress, when it built rapport and comfort, and when it expressed empathy, humor, or solidarity. One patient described appropriate swearing as motivational, affirming, and complimentary, while another said it depended on the relationship the clinician had built with the patient. These responses align with sociolinguistic findings that swearing can reduce social distance, signal shared identity, and communicate authenticity.

When asked when swearing is inappropriate, patients centered their answers on individual patient characteristics. Many highlighted age, noting that swearing should be avoided with young children and with older adults, reflecting generational differences in tolerance of taboo language. Others emphasized patient comfort and consent, with one respondent saying swearing is inappropriate if the client is not comfortable with it and another if a patient has explicitly stated so. Patients also cautioned against swearing directed at rather than with the patient, swearing in frustration or anger, and swearing during serious clinical conversations. Notably, a subset of patients rejected clinician swearing outright, responding simply with never or always inappropriate, underscoring that while many patients view swearing as conditionally acceptable, it remains unacceptable for others.

The authors interpret these findings through the lens of established rehabilitation science. Motivation in physical rehabilitation is increasingly understood as dynamic and shaped by social and environmental factors, including the clinician’s interpersonal style, and clinicians perceived as kind, welcoming, and genuinely engaged can positively influence patient motivation. Swearing, when used appropriately, may contribute to a relaxed, authentic clinical atmosphere that fosters rapport and communicates solidarity. Self-confidence, which commonly declines after injury and is strongly associated with functional outcomes, can be restored through verbal persuasion, and swearing during encouragement may deliver a more intense and emotionally resonant form of that persuasion. Adherence, closely tied to the therapeutic alliance, may benefit when swearing injects humor and informality into sessions, making rehabilitation feel less sterile and more engaging.

Importantly, the study suggests that swearing may operate more as a threshold effect than a dose-response effect. Higher frequency did not reliably increase perceptions of unprofessionalism or offensiveness, and frequent swearing was actually linked with greater perceptions of patient-centeredness, but the presence of swearing itself, rather than its frequency, may drive patient perceptions. The authors also note that different swear words carry different levels of impact, which were not measured in this study and could complicate simple frequency effects. The team offers practical recommendations: when in doubt, don’t swear; use it sparingly and with purpose; align with patient preferences; never swear in anger or at the patient; and prioritize authenticity. The researchers caution that the findings are preliminary, underpowered, and context-dependent, and they call for preregistered, confirmatory studies with larger, more representative samples across diverse clinical settings before swearing can be recommended as a clinical strategy.

Subject of Research: Patient perspectives on clinician swearing during physical rehabilitation

Article Title: Do patients give a damn? An exploratory study of patient perspectives on clinician swearing during physical rehabilitation

Article References: Mercer, A., Meakins, A., St. Martin, R., Trummer, G., Geoghagan, L., Muscha, K., & Washmuth, N. B. (2026). Do patients give a damn? An exploratory study of patient perspectives on clinician swearing during physical rehabilitation. Frontiers in Rehabilitation Sciences, 7, Article 1719743. https://doi.org/10.3389/fresc.2026.1719743

Image Credits: AI Generated

DOI: 10.3389/fresc.2026.1719743

Keywords: swearing, physical rehabilitation, patient perspectives, therapeutic alliance, motivation, self-confidence, treatment adherence, patient-centered care, communication, physiotherapy, patients, give

The study, conducted at Bafoussam Regional Hospital between January 2023 and December 2024, enrolled 47 patients with chronic low back pain, defined as pain persisting for more than six months. Participants were overwhelmingly women engaged in agricultural work, with 78.7 percent female and a mean age of 44.8 years. Crucially, 95.7 percent had already failed a course of physiotherapy before entering the study, making this one of the most treatment-resistant populations imaginable. Patients were allocated not by randomization but by the day they happened to consult: those arriving on Mondays and Wednesdays received osteopathic care, while Tuesday, Thursday, and Friday attendees received physiotherapy, reflecting the real-world organization of the hospital’s services.

The two interventions differed substantially in structure and dose. The osteopathic protocol consisted of ten 45-minute sessions over five weeks, progressing from structural assessment and spinal mobilization through correction of kinetic chain dysfunction to stabilization and postural education tailored to farming tasks. The physiotherapy protocol comprised fifteen 30-minute sessions over the same period, combining transcutaneous electrical nerve stimulation, infrared thermotherapy, passive mobilization, progressive core strengthening, and functional re-athletization exercises such as hoeing simulation and load carrying. Both protocols were explicitly adapted to the biomechanical demands of rural agricultural life, where hoeing, carrying, and repetitive bending dominate daily labor.

Across the five-week intervention, the osteopathic pathway showed larger magnitudes of improvement on both primary outcomes. Pain intensity, measured on the Visual Analog Scale, fell by 47.3 percent in the osteopathy group compared with 32.1 percent in the physiotherapy group, a difference that reached statistical significance with a large effect size of Cohen’s d equal to 0.85. Functional disability, assessed with the Eifel Disability Index, improved by 42.8 percent versus 31.5 percent, with a moderate-to-large effect size of 0.73. Patients receiving osteopathic care also required significantly fewer sessions, 9.8 on average compared with 14.1, and reported higher satisfaction scores of 8.4 versus 7.3 on a ten-point scale.

Beyond pain and function, the study introduced two novel assessment instruments developed specifically for the rural African context. The Therapeutic Autonomization Score, validated through a modified Delphi process with expert panels and cognitive interviews in French and the local Bamiléké language, measures four domains of patient self-management: knowledge acquisition, correct execution of exercises, practice regularity, and activity adaptation. Osteopathy patients scored 16.2 out of 20 compared with 13.8 for physiotherapy patients, a difference the authors suggest may be crucial where ongoing professional support is scarce. The Agricultural Functional Test, built from ten days of field observation of 47 common farming tasks, evaluates load-bearing capacity, sustained hoeing tolerance, functional bending, and lower-limb endurance, achieving inter-rater reliability above 0.75 for every component.

The qualitative findings may prove as influential as the quantitative ones. Patients in the osteopathy group consistently described immediate sensations of structural release, often accompanied by audible joint cavitation. One 52-year-old farmer who traveled five hours from Yaoundé reported feeling something click back into place, comparing it to unlocking a door that had been stuck for months. Physiotherapy patients, by contrast, described gradual, effort-dependent recovery, dependence on external modalities like heat and electrotherapy, and structural barriers to adherence stemming from distance and agricultural workload. The authors interpret this divergence as a fundamental difference in therapeutic temporality: osteopathy delivers instantaneous, embodied relief, while physiotherapy cultivates slower functional gains that demand sustained engagement.

From these observations, the research team articulated what they call the unique practitioner syndrome, a phenomenon in which disproportionate therapeutic attraction develops around a professional exercising rare competencies in a context of structural absence of local alternatives. The framework encompasses four interconnected mechanisms: credential-based therapeutic authority, in which internationally recognized training, particularly the practitioner’s Sorbonne University credentials and so-called France-diploma effect, functions as a primary determinant of therapeutic legitimacy; therapeutic scarcity dynamics, documented through patients traveling more than 200 kilometers specifically to access osteopathic care unavailable elsewhere; treatment experience saturation, the categorical resistance that develops after repeated failures with a single modality; and practitioner-centered therapeutic orientation, where confidence becomes embodied in the person of the healer rather than in specific procedures.

The economic observations, though descriptive rather than a formal cost-effectiveness analysis, add a practical dimension. Direct treatment costs averaged 47,500 Central African CFA francs, roughly 77 US dollars, for the osteopathic pathway versus 62,800 francs, about 101 dollars, for physiotherapy, a 24.4 percent difference. Because the average patient traveled two to four hours each way for treatment, the 4.3-session reduction associated with osteopathy translated to an estimated 32,400 francs, approximately 52 dollars, in avoided lost agricultural productivity per patient, based on regional daily income estimates of 6,000 francs.

Safety profiles were acceptable in both arms. The osteopathy group experienced no adverse events, while two physiotherapy patients, 7.1 percent of that group, developed minor superficial burns from prolonged infrared thermotherapy that resolved within 48 to 72 hours after parameter adjustment. The authors note that such events underscore the importance of careful monitoring when applying physical modalities in populations with potentially different skin sensitivity characteristics or limited prior exposure to technological therapeutic interventions.

The authors are unusually candid about their limitations, and these caveats fundamentally shape how the findings should be read. The non-randomized allocation by consultation day introduces potential selection bias that precludes causal inference. More seriously, the principal investigator simultaneously delivered the osteopathic intervention and conducted outcome assessments, a dual therapist-assessor role the authors themselves describe as a fundamental methodological flaw that likely inflated effect sizes in favor of osteopathic treatment. The highly selective population, with 95.7 percent prior physiotherapy failure, limits generalizability, the five-week window prevents evaluation of treatment durability, and the small sample of 47 patients precluded multivariate analysis. The observed effect sizes, which exceed those typically reported in osteopathic systematic reviews, likely represent an upper-bound estimate. The research team positions the study explicitly as hypothesis-generating rather than confirmatory, and they call for rigorously designed, adequately powered randomized controlled trials with blinded assessment, multi-site implementation, representative populations, and extended follow-up of twelve months or longer. Within those constraints, the study delivers genuine methodological innovations, including the first validated autonomization instrument for sub-Saharan African populations and a functional test grounded in the actual labor of rural farmers, alongside a conceptual framework that may reshape how health services research understands therapeutic authority in settings where one practitioner can become, in effect, the entire referral network.

Subject of Research: Comparative pilot study of osteopathic care versus physiotherapy for chronic low back pain in rural Cameroon and the healthcare-seeking phenomenon of the unique practitioner syndrome

Article Title: Chronic low back pain management in rural Cameroon: a pragmatic pilot study of osteopathic care, physiotherapy, and the “unique practitioner syndrome”

Article References: Moumeni, I. N., Moumeni, A.-N. N., Orlsiter, T. K. B., & Atemkeng-Tsatedem, F. (2026). Chronic low back pain management in rural Cameroon: a pragmatic pilot study of osteopathic care, physiotherapy, and the “unique practitioner syndrome”. Frontiers in Musculoskeletal Disorders, 3, Article 1716794. https://doi.org/10.3389/fmscd.2025.1716794

Image Credits: AI Generated

DOI: 10.3389/fmscd.2025.1716794

Keywords: chronic low back pain, osteopathy, physiotherapy, rural Cameroon, unique practitioner syndrome, manual therapy, pilot study, rehabilitation, therapeutic autonomization, agricultural functional test, health services research, sub-Saharan Africa

The research team, led by Michael Minor of the Essener Forschungsinstitut für Medizinmanagement (EsFoMed) in Essen, Germany, searched Embase, PubMed, and Web of Science through May 2025. Following the Cochrane Handbook and reporting under the PRISMA 2020 checklist, they screened more than 7,000 records and ultimately included eleven randomized controlled trials: eight in physiotherapy, two in speech therapy, and one in occupational therapy. Crucially, the team only accepted studies in which the group and individual interventions followed identical therapy protocols, ensuring that any observed differences could be attributed to the delivery format rather than the treatment content itself.

The scope of the included trials was remarkably broad. In physiotherapy, studies examined constraint-induced movement therapy, task-oriented circuit training, and mirror therapy for stroke patients, exercise training for children with developmental coordination disorder, pelvic floor muscle training for women with stress urinary incontinence, multimodal programs for Parkinson’s disease and chronic knee pain, and strength training for resistance-trained men. The speech therapy trials covered voice therapy for children with vocal fold nodules and narrative-based language intervention for children with cochlear implants, while the single occupational therapy study applied a developmental floortime model to toddlers with autism.

Across these eleven trials, the researchers evaluated 76 distinct outcomes spanning motor function, voice-related measures, adaptive behavior, activities of daily living, pain, quality of life, and process indicators such as attendance and satisfaction. The headline finding is that 67 of those 76 outcomes showed no statistically significant difference between group and individual therapy after intervention. Group therapy produced better results in five outcomes, individual therapy in four. In other words, the delivery format appears to matter far less than the therapy itself.

Some nuances emerged within the noise. In stroke rehabilitation, group-based circuit training and constraint-induced movement therapy occasionally favored the group format, with one trial reporting significantly higher gait speed gains measured by the six-minute walk test, and another showing larger improvements on the Motor Activity Log and Action Research Arm Test in group participants. Conversely, a mirror therapy trial found that resistance to passive movement of the finger flexors improved more in individual sessions. In the voice therapy study, individual participants achieved a higher s/z ratio while group participants scored better on the noise harmonic ratio. Therapists in the pediatric voice study also noted that group sessions were more enjoyable, with patients appearing more competitive and motivated.

One trial stood apart for its focus on healthcare delivery rather than clinical endpoints. It found that group therapy participants waited fewer days before starting treatment, allowing earlier intervention, while staff burden did not increase and nonattendance rates remained similar to individual care. This process advantage is significant given the scale of demand: in Germany alone, roughly 334 million treatments were performed in 2025, with physiotherapy accounting for approximately 271 million of them. Yet less than 0.1 percent of physiotherapy treatments, 1.6 percent of occupational therapy treatments, and 0.5 percent of speech therapy treatments were delivered in group format, despite policy that nominally prioritizes group delivery for cost-effectiveness.

The methodological verdict, however, tempers any enthusiasm. Using the Cochrane RoB 2 tool, the reviewers judged eight of the eleven studies to carry a high overall risk of bias, with the remaining three raising some concerns; no study achieved low risk across all domains. High risks clustered around deviations from intended interventions and missing outcome data, often reflecting absent pre-registered protocols and unspecified analysis plans rather than clearly flawed conduct. Applying the GRADE framework, the certainty of evidence was rated low or very low for every outcome domain, driven primarily by the very serious risk of bias and, in most domains, cumulative sample sizes below 400 participants.

The heterogeneity problem proved equally formidable. Patient populations ranged from toddlers with autism to resistance-trained males, group sizes fluctuated between two and ten participants, interventions lasted from two to twelve weeks with sessions of 30 to 180 minutes, and outcome instruments varied from the Fugl-Meyer Test to the Adaptive Behavior Assessment System. Because effect estimates were not sufficiently comparable, the authors could not perform a meta-analysis and instead synthesized results narratively. Notably, every included trial was conducted in person; despite the search strategy permitting digital formats with synchronous video communication, no qualifying telemedicine studies were identified, leaving the effectiveness of digital group therapy entirely unexamined.

The authors are careful about what their null findings do and do not mean. Most trials were powered only to detect medium or large effects, so small but clinically meaningful differences may have gone undetected. Statistical non-significance, they emphasize, is not proof of equivalence; observing similar mean outcomes differs from demonstrating equal effectiveness. The findings align with prior reviews, including work on developmental coordination disorder, stroke and ischemic heart disease recovery, post-stroke upper limb interventions, and physical therapy for urinary incontinence and low back pain, all of which similarly failed to establish consistent differences between formats while acknowledging limited evidence quality.

The practical implications remain tantalizing but unproven. Group therapy could simultaneously treat more patients, shorten waiting times, and stretch limited rehabilitation resources, and the single trial measuring process indicators offered a glimpse of that promise. But with only eleven studies, pronounced imbalance across the three therapeutic disciplines, several small pilot trials, and no cost comparisons among the included studies, the review cannot yet declare which indications suit group delivery. The authors call for future research with strong methodological frameworks, adequately powered samples, and attention to both costs and treatment effects, particularly in speech therapy and occupational therapy where evidence remains scarcest. Until then, the choice between group and individual therapy rests on judgment, logistics, and hope rather than on solid evidence.

Subject of Research: Systematic review comparing group and individual therapy delivery formats across physiotherapy, occupational therapy, and speech therapy finds no clear evidence favoring either format.

Article Title: Comparison of group and individual therapy in physiotherapy, occupational therapy, and speech therapy: a systematic review

Article References: Minor, M., Plath, E., Volland, C., Neusser, S., & Bußmann, A. (2026). Comparison of group and individual therapy in physiotherapy, occupational therapy, and speech therapy: a systematic review. Frontiers in Rehabilitation Sciences, 7, Article 1904321. https://doi.org/10.3389/fresc.2026.1904321

Image Credits: AI Generated

DOI: 10.3389/fresc.2026.1904321

Keywords: group therapy, individual therapy, physiotherapy, occupational therapy, speech therapy, systematic review, rehabilitation, randomized controlled trials, risk of bias, GRADE, telemedicine, healthcare delivery

The study, led by Ronald Bwambale of Makerere University’s School of Public Health together with colleagues in Uganda and the United States, followed 120 adult stroke patients discharged from the Mulago Neurology unit between February and May 2025. The unit, which records between 40 and 60 newly diagnosed stroke patients each month, recommends that discharged patients continue rehabilitation at nearby facilities. But the researchers found that the journey from hospital bed to sustained therapy is riddled with obstacles, most of them financial.

To measure access rigorously, the team used a 17-item multidimensional tool based on Penchansky and Thomas’s classic framework, which breaks access into five dimensions: availability, accessibility, accommodation, affordability, and acceptability. Each item was scored on a five-point Likert scale, and participants scoring 80 percent or above on the composite measure were classified as having high access. The results were stark. Affordability scored lowest at just 3.7 percent, followed by accommodation at 15.9 percent, availability at 20.6 percent, and accessibility at 24.3 percent. Only acceptability, at 66.4 percent, approached adequate levels.

The affordability finding is the study’s most alarming. In-depth interviews with six purposively selected participants revealed that patients were paying out of pocket for every physiotherapy session on top of ongoing medication costs. One 75-year-old male participant described hiring a private healthcare worker who charged 80,000 Ugandan shillings, roughly 22 US dollars, per two-hour session, while weekly medications cost another 85,000 shillings. The combined burden proved unsustainable, and the family eventually stopped rehabilitation altogether. This pattern of discontinuation due to cost was a recurring theme across interviews.

Transport emerged as the second major barrier. Many patients lived far from the few facilities equipped to provide stroke rehabilitation, which in Uganda are concentrated in national and regional referral hospitals. Long travel distances made consistent attendance difficult, pushing some patients to abandon therapy after just a few sessions. Even those living relatively close faced challenges, as one caregiver explained that she could not expose her vulnerable relative to the wind on a motorcycle taxi, known locally as a boda-boda, without triggering vomiting. For others, the cost of fuel or hired transport fell on already strained family members, with some patients themselves contributing money toward trips they could not afford.

The organization of rehabilitation services also fell short of patient needs. Participants reported that rehabilitation at some facilities was available only during morning hours, leaving afternoon arrivals unattended even when staff were present. Long waiting times and confusing referral pathways within the hospital system led to missed appointments and frustration. One 34-year-old female participant described being sent from one department to another without clear direction, ultimately leaving at 6 p.m. without seeing a doctor. In contrast, patients who accessed private rehabilitation services reported more organized care, with scheduled appointments and even occasional home visits, highlighting a two-tier system that favors those who can pay.

Faced with these barriers, many families improvised. Some patients shifted to self-directed exercises at home, guided by relatives, friends with medical knowledge, or instructional videos found online. While this resourcefulness reflects resilience, the researchers note that unguided home exercise cannot substitute for professional rehabilitation, particularly during the early post-stroke window when structured therapy has the greatest impact on functional recovery. The study also found that higher access was reported among younger participants, urban residents, those of higher socio-economic status, and married individuals, suggesting that the burden of poor access falls disproportionately on older, rural, and less connected patients.

The acceptability dimension’s relatively high score deserves careful interpretation. The authors suggest it may reflect the limited autonomy stroke patients have in choosing providers. Given their urgent need for rehabilitation, patients often accept whatever care is available regardless of provider characteristics, meaning the score may indicate willingness to receive care rather than genuine satisfaction with its quality. This nuance matters for policymakers who might otherwise read the 66.4 percent figure as a sign that the system is working.

The findings land within a broader global context. Stroke is the second leading cause of death worldwide, and roughly 70 percent of strokes and 87 percent of stroke-related disabilities occur in low- and middle-income countries. In Africa, stroke incidence reaches up to 316 per 100,000 annually, with a three-year fatality rate exceeding 80 percent. In Uganda specifically, stroke is the sixth leading cause of death and the third most diagnosed neurological condition, with a 30-day mortality rate of 38.1 percent. Yet at least 63 percent of Africans needing rehabilitation do not receive it, a gap the World Health Organization’s Rehabilitation 2030 initiative has flagged as a systemic failure driven by under-prioritization, inadequate funding, and shortages of trained rehabilitation professionals.

The researchers propose concrete interventions tailored to this context. They recommend subsidizing community-based rehabilitation services to reduce out-of-pocket costs, extending service hours beyond mornings, strengthening caregiver training before discharge so families can support affordable home-based care, and decentralizing rehabilitation points to regional, district, and community levels. They also point to home-based and community-led rehabilitation models, which evidence shows can be effective even in resource-limited settings, as well as tele-rehabilitation and mobile health interventions that could extend services to rural populations. Public-private partnerships, they argue, could expand affordable care in underserved areas. Without such reforms, the study warns, the majority of Uganda’s stroke survivors will continue to face recovery alone, their rehabilitation cut short by the price of a bus fare or a therapy session.

Subject of Research: Access to post-discharge stroke rehabilitation services in Kampala, Uganda

Article Title: Access to stroke rehabilitation services for patients discharged from the Mulago National Referral Hospital Neurology unit, Kampala—Uganda: a mixed-methods study

Article References: Bwambale, R., Ssenyonga, R., Kaddumukasa, M., Sajatovic, M., & Mukose, A. D. (2026). Access to stroke rehabilitation services for patients discharged from the Mulago National Referral Hospital Neurology unit, Kampala—Uganda: a mixed-methods study. Frontiers in Stroke, 5, Article 1913292. https://doi.org/10.3389/fstro.2026.1913292

Image Credits: AI Generated

DOI: 10.3389/fstro.2026.1913292

Keywords: stroke, rehabilitation, Uganda, Mulago National Referral Hospital, health access, affordability, low- and middle-income countries, physiotherapy, mixed-methods research, global health, stroke recovery, health policy

The research, carried out in the physiotherapy and rehabilitation outpatient clinic of a hospital in Malatya, Türkiye, surveyed 198 patients between November 2023 and February 2024. Notably, this period fell in the aftermath of the February 2023 Kahramanmaraş earthquakes, a context the authors explicitly flag as important when interpreting their findings. Participants completed the 29-item Outpatient Patient Satisfaction Scale, which yields a mean item score ranging from 1 to 5, alongside questions covering sociodemographic characteristics, admission-related details and features of the hospital environment.

The headline result was that overall satisfaction fell in the moderate to high range, with a median total score of 3.7 and an interquartile range of 3.1 to 4.1. Within the scale, the staff attitude subscale scored highest, suggesting that interpersonal aspects of care remained a relative strength, while the waiting time and counselling subscale scored lowest. The instrument itself demonstrated excellent internal consistency, with a Cronbach’s alpha of 0.962, indicating that the 29 items hung together remarkably well as a measure of the overall outpatient experience.

To move beyond simple associations, the researchers employed multivariable linear regression, a statistical technique that allows each factor’s independent contribution to be estimated while holding all other measured variables constant. Cleanliness and ventilation/heating were entered as indicator variables, allowing the model to capture graded differences between response categories rather than treating them as simple yes-or-no attributes. The model achieved an adjusted R-squared of 0.331, meaning that roughly a third of the variation in total satisfaction scores could be explained by the factors examined.

The findings on cleanliness were particularly striking. Compared with patients who rated the clinic as very clean or clean, those who described it as clean but not adequate showed a reduction in total satisfaction score of 0.469 points, while those who said it was not clean showed a reduction of 0.986 points, both statistically significant at p less than 0.001. This graded pattern, in which satisfaction declines stepwise as perceived cleanliness worsens, suggests that even intermediate levels of perceived inadequacy carry a measurable penalty, and that improvements in cleaning standards could yield proportional gains in patient experience.

Waiting time also emerged as an independent predictor. For every additional minute of examination waiting time, the total satisfaction score dropped by 0.005 points, a small per-minute effect that nonetheless accumulates meaningfully over longer waits. Similarly, patients who rated the ventilation and heating system as could-be-better rather than adequate showed a 0.260-point reduction in satisfaction, independent of other factors. Female sex was also associated with a lower total score, with a coefficient of −0.209 and a p-value of 0.041, although the robustness of this particular finding proved more fragile under sensitivity testing.

Indeed, the authors took care to probe the stability of their results. Influence diagnostics identified 11 observations with disproportionate leverage on the model, and when these were excluded, the associations with cleanliness, waiting time and ventilation/heating remained materially unchanged. The association with female sex, however, was no longer statistically significant in that sensitivity analysis, a reminder that single-variable findings in moderately sized cross-sectional samples should be interpreted with appropriate caution until replicated in other settings.

What makes this study notable is its reframing of what matters in outpatient physiotherapy. The physiotherapy literature has historically emphasised the therapeutic relationship, the skill and demeanour of the therapist, and the quality of the hands-on intervention. Those elements remain important, and the high score on the staff attitude subscale in this study suggests they are being delivered well. But the regression results indicate that even when interpersonal care is strong, patients notice and are influenced by the state of the physical environment around them, by how long they sit waiting, and by whether the room feels adequately heated and ventilated. These are modifiable factors, often addressable through operational and facilities management rather than clinical retraining.

The post-earthquake context adds a further layer of interpretation. Malatya was among the regions severely affected by the February 2023 earthquakes, and health services operating in the aftermath face strained infrastructure, displaced populations and heightened patient vulnerability. The authors caution that the setting should be borne in mind when generalising the findings, since environmental perceptions and expectations may differ under disaster recovery conditions. At the same time, the study offers a rare window into patient experience in post-disaster health service delivery, a topic that remains underexplored in the health services research literature.

For clinic managers and health policy makers, the practical implications are tangible. Prioritising visible cleanliness, reducing examination waiting times and ensuring adequate ventilation and heating are concrete, measurable targets that could improve patient satisfaction without requiring changes to clinical practice itself. The authors position these environmental and access-related factors as potential targets for further evaluation, and the graded association with cleanliness in particular invites intervention studies to test whether improvements translate directly into better patient-reported experience. As health systems worldwide grapple with rising demand for rehabilitation services, this study suggests that the path to higher satisfaction may run through corridors, waiting rooms and heating systems as much as through the treatment table.

Subject of Research: Factors independently associated with patient satisfaction among physiotherapy outpatients, including cleanliness, waiting time and ventilation, in a post-earthquake Turkish hospital setting.

Article Title: Factors independently associated with patient satisfaction in a physiotherapy outpatient clinic: a cross-sectional study

Article References: Yavuz, Z. A., Kurt, O., & Erdoğan, K. (2026). Factors independently associated with patient satisfaction in a physiotherapy outpatient clinic: a cross-sectional study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15878-0

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15878-0

Keywords: patient satisfaction, physiotherapy, outpatient care, health services research, cleanliness, waiting time, ventilation, cross-sectional study, post-earthquake health services, quality of health care, multivariable regression, hospital environment