Transcranial magnetic stimulation (TMS) is a noninvasive brain stimulation (NIBS) technique that can directly manipulate neural activity in different cortical areas (Rossini and Rossi, 2007). It generates a magnetic field on a coil resting on the scalp, which induces electric currents in the brain, spinal roots, or nerves (Londero et al., 2006; Chail et al., 2018). This electrical current can depolarize neurons or their axons if the current’s amplitude, duration, and direction are appropriate (Chail et al., 2018); as a result, increased or decreased cortical activity occurs in that area of the brain, which can be related to functional changes (Londero et al., 2006; Lefaucheur et al., 2014). TMS can be used in clinical and research settings for individuals with and without neurological dysfunctions (US Food and Drug Administration, 2015; Saudi Food and Drug Authority SFDA, 2016; AlHadi et al., 2017; Deng et al., 2020; Kim et al., 2011; Zeina et al., 2014; Baradi and Shahid, 2017; Al-Sultan et al., 2019). The United States Food and Drug Administration (FDA) and the Saudi FDA have approved the clinical use of TMS for treating adult patients with depression who have failed to show significant improvement with antidepressant medications (U.S. Food and Drug Administration, 2015; Saudi Food and Drug Authority SFDA, 2016). In addition to its medical use, TMS has been widely applied in different rehabilitation settings for individuals with neurological and musculoskeletal conditions (Kim et al., 2011; Zeina et al., 2014; AlHadi et al., 2017; Baradi and Shahid, 2017; Al-Sultan et al., 2019; Deng et al., 2020). Specifically, stimulating the motor cortex with TMS improves performance among patients with motor impairments (Zeina et al., 2014; Baradi and Shahid, 2017).

Enhancing motor performance is a core goal for physical therapy interventions; therefore, in the past few decades, there has been vigorous growth in the range of rehabilitation technologies, such as noninvasive brain stimulation (NIBS), that can improve the recovery of patients with motor impairments (Winstein et al., 2016; Palmer et al., 2018; Winstein and Varghese, 2018; Al-Hussain et al., 2021; Bashir et al., 2021; Braun and Wittenberg, 2021). Specifically, combining TMS with different rehabilitation techniques to improve motor recovery has been widely investigated. For instance, TMS with constrained induced movement therapy (CIMT) has been shown to be superior to CIMT alone for improving upper limb functions in patients who have suffered a stroke (Abdullahi et al., 2023). In addition, TMS applications have been associated with improved motor function, learning, and consolidation in healthy individuals and individuals who have suffered a stroke (Dayan and Cohen, 2011). A recent study demonstrated the efficacy and feasibility of utilizing TMS in different rehabilitation settings (Braun and Wittenberg, 2021). TMS can also be used to investigate changes in motor cortex excitability and muscle representation in the motor cortex following different rehabilitation paradigms (Palmer et al., 2018; Braun and Wittenberg, 2021; Abdullahi et al., 2023). For example, increased cortical excitability and upper limb muscle representation in the primary motor area (M1) have been reported following rehabilitation intervention for patients who have suffered a stroke (Braun and Wittenberg, 2021). Thus, incorporating TMS into rehabilitation is important for augmenting patients’ motor recovery and facilitating functional independence.

However, the effectiveness of TMS could vary depending on the coli shape, size, orientation, and magnetic field intensity, frequency, and duration (Rossini and Rossi, 2007; Rossi et al., 2009; León Ruiz et al., 2018). The absence of a standardized protocol for TMS modalities has limited achieving optimal and effective therapeutic outcomes (Kim et al., 2020; Lefaucheur et al., 2020; Vallejo et al., 2023). In addition, individual variability in the degree to which there is facilitation or inhibition has been reported (Maeda et al., 2000). The variability in the outcomes of TMS therapy among patients may be attributed to factors such as genetic variations, the timing of TMS application in regard to disease severity, the underlying pathology, and the specific parameters employed during the therapy administration (Maeda et al., 2000; Chervyakov et al., 2015; Vallejo et al., 2023). In fact, there is still a need for more evidence regarding the reliability of TMS effects within and among studies in research and clinical settings (Nazarova and Asmolova, 2022).

Although some current evidence supports the use of TMS in medical and research settings, its usability in research and clinical studies in Saudi Arabia has not been explored in depth. This could be related to different factors. One of the most critical factors reported in previous studies is patients’ misconceptions about their examination or treatment, as explained by their healthcare provider; this, in turn, is directly impacted by the healthcare provider’s knowledge (Dowman et al., 2005). Current studies have shown that knowledge of and positive attitudes toward brain stimulation techniques significantly correlate with therapeutic referrals (Dauenhauer et al., 2011; AlHadi et al., 2017; Deng et al., 2020). A study conducted in Saudi Arabia involving 96 psychiatrists assessed their knowledge and acceptability of repetitive TMS (rTMS) utilizing an online survey. The study showed that 80% of respondents thought they had good knowledge of rTMS, 79% had a positive attitude toward this technique, and more than half were willing to consider it as a treatment approach (AlHadi et al., 2017). The survey concluded that knowledge and attitudes were correlated with the implementation of rTMS among psychiatrists in Saudi Arabia. These findings aligned with similar studies in other countries (Gazdag et al., 2004; Dan et al., 2014; Raharjanti et al., 2022). Thus, knowledge and attitudes are important factors to consider in expanding and facilitating the use of TMS in rehabilitation.

While numerous studies have explored the knowledge and attitudes of patients and psychiatrists towards transcranial magnetic stimulation (TMS) (Gazdag et al., 2004; Dowman et al., 2005; Dauenhauer et al., 2011; AlHadi et al., 2017; Deng et al., 2020), there has been limited investigation into the understanding and perceptions of TMS among professionals outside the field of psychiatry. The significance of comprehending the rehabilitative aspects and practicality of TMS cannot be overstated, as it directly impacts its clinical implementation. Notably, no previous studies have examined the knowledge and attitudes of rehabilitation specialists towards TMS. Hence, this study aims to conduct the first assessment of TMS knowledge and attitudes among rehabilitation specialists in Saudi Arabia.

An observational cross-sectional study was carried out through the anonymous distribution of an online survey. A self-administered questionnaire on knowledge of and attitude toward TMS was adapted from a previous study that evaluated this topic among psychiatrists in Saudi Arabia (AlHadi et al., 2017). The questionnaire was modified to measure knowledge and attitudes regarding the applications of TMS in rehabilitation. A convenience sampling approach targeted registered rehabilitation specialists such as physical, Occupational, and speech-language therapists in Saudi Arabia to explore their knowledge and attitudes regarding TMS applications in the rehabilitation sciences.

This study used a self-administered survey to explore rehabilitation knowledge of and attitudes toward TMS in Saudi Arabia. The number of female respondents was slightly higher than that of males, which is similar to previous studies; a higher proportion of females could reflect that rehabilitation practice in Saudi Arabia is as independent as other medical and health specialties with discrepancy of gender distribution across all the medical fields (Hussein et al., 2022). Our respondents’ mean age was similar to other studies (Mouton et al., 2014). Most of our respondents were bachelor’s degree holders practicing under various rehabilitation subspecialties, and only a few specialized in neurorehabilitation. A similar statistic was reported in previous studies, demonstrating relatively low numbers of post-professional and specialized therapists compared to the number of bachelor’s physical therapy degrees and clinical Doctor of Physical Therapy (DPTs) (Bindawas, 2014; Alghadir et al., 2015; Yorke et al., 2016). Most of our responses were from the central region of Saudi Arabia due to the large number of rehabilitation programs and a wide range of hospitals, as reported in previous studies in Saudi Arabia (Bindawas, 2014; Al-Eisa et al., 2016).

One of the study’s aims was to assess basic TMS knowledge among different subgroups of rehabilitation specialists. Most of the respondents did not have TMS equipment or experience and felt their knowledge of TMS applications was limited. The lack of TMS equipment could explain the low TMS knowledge among our participants, as previous research has demonstrated that a lack of equipment and workspace in rehabilitation is considered a common barrier to translating knowledge into practice while providing equipment would be regarded as a facilitator of knowledge applicability (Graham et al., 2006; Weatherson et al., 2017; Moncion et al., 2020). Most participants indicated that they were aware that TMS has the potential to be used as a treatment tool for neurological diseases and could be used to activate various brain areas, but not as a diagnostic tool. This could be attributed to the fact that physicians commonly handle patients’ diagnoses before their referral for rehabilitation interventions in most practices in Saudi Arabia, which could impact our participants’ knowledge of TMS usage as a diagnostic tool (Al-Eisa et al., 2016). We also found a lack of knowledge among our participants regarding TMS contraindications and the unnecessary use of hospital admission or muscle relaxants. This could be attributed to discrepancies between studies on TMS safety and what is considered an absolute TMS contraindication rather than a reason to apply it with caution (Wassermann, 1998; Tope and Shellock, 2002; Perera et al., 2016; AlHadi et al., 2017; McClintock et al., 2017; Shah et al., 2019; Deng et al., 2020; Vallejo et al., 2023).

The overall average knowledge score was low (7.81 ± 6.20), and only 40% of the respondents obtained more than 50% of the maximum possible knowledge score. This could be because most of our participants did not have TMS equipment in their workplaces and were not post-professional degree holders, which might be attributed to the lack of post-professional rehabilitation and residency programs in Saudi Arabia (Bindawas, 2014; Alghadir et al., 2015). In addition, limited TMS research has been conducted among rehabilitation specialists in Saudi Arabia (Al-Hussain et al., 2021; Bashir et al., 2021). TMS is still considered a new concept to be addressed in rehabilitation in Saudi Arabia, and brain stimulation is not covered in the curriculum of bachelor’s degree programs in rehabilitation science. We also found that the overall knowledge score was higher for respondents with master’s and doctoral degrees and demonstrated a significant relationship between TMS knowledge and education levels in all of our respondents, including the subgroup of neurorehabilitation specialists. Additionally, specialists with previous experience with TMS applications had significantly more knowledge than those without experience. This study did not find an effect of gender, age, region, main source of knowledge, type of workplace, or subspecialty on overall TMS knowledge. These findings are aligned with previous studies conducted among psychiatrists evaluating their knowledge of TMS in Saudi Arabia (Walter et al., 2001; AlHadi et al., 2017).

Overall, most of the participants had a neutral perception of TMS. However, more than half of the participants reported that all rehabilitation specialists should attend training courses on TMS applications, in which interns speak for the need for TMS training and educational courses among rehabilitation specialists. Approximately 43.14% of respondents had confidence that TMS applications would enhance the quality of care in rehabilitation and indicated that sufficient knowledge is crucial in neurorehabilitation practice. Thus, emphasizing knowledge of TMS is essential for its application by rehabilitation specialists. Only 25.49% of the respondents indicated that they would recommend TMS as a potential adjunct therapy; 23% agreed that there is still no sufficient evidence of TMS efficacy in rehabilitation, while 41.18% of participants believed that more TMS research studies should be implemented in Saudi Arabia. This reflects the current controversy and limitations of TMS applications and effectiveness in the literature (Vallejo et al., 2023), as well as specialists ' need for more education programs and the implementation of TMS in Saudi Arabia. More TMS research is needed among rehabilitation specialists in Saudi Arabia. The average attitude score was 40.58 ± 4.91 out of a maximum score of 65 (or 62.43%), which showed a significant positive attitude toward TMS in rehabilitation. The attitude score was significantly more positive in participants who reported the presence of TMS equipment in their workplace, had previous experience with TMS devices, and reported having sufficient knowledge about TMS applications. Similar positive attitudes toward TMS among psychiatrists in Saudi Arabia were reported in previous studies (Walter et al., 2001; AlHadi et al., 2017). These results and previous studies support the idea that knowledge, experience, and TMS availability are crucial for facilitating TMS implementation among rehabilitation specialists.

Based on this study’s findings, we recommend advancing knowledge on the use of TMS among rehabilitation specialists; we recommended incorporating TMS topics in educational programs, especially in the courses that address neuroplasticity concepts in rehabilitation, to better understand the mechanism and rationale for using TMS in Saudi Arabia. Also, rehabilitation students in undergraduate and graduate rehabilitation programs should be encouraged to have their graduation research projects on TMS. Moreover, since FDA approves TMS for psychiatric disorders and the TMS equipment is available in psychiatric departments, building collaboration with these departments would foster the knowledge and attitude toward using TMS in rehabilitation and increase access to TMS devices. Conducting workshops and scientific meetings on TMS applications and safety would also improve the knowledge and attitude toward TMS in rehabilitation.

Nevertheless, this study had some limitations. The survey was implemented with Google Forms, which implies that the responding specialists use computer support. Moreover, most of our participants were from the central region of Saudi Arabia, which could limit the generalizability of the results to the other areas. Additionally, the survey targeted rehabilitation specialists and did not include all healthcare providers, such as medical doctors and nurses. Further validation of our findings in other populations of medical practitioners is needed to assess their knowledge and attitudes toward TMS in rehabilitation. Another limitation of this study is that it did not focus on neurorehabilitation specialists or neurologists to capture their knowledge and attitude toward TMS application in Saudi Arabia. Our study only included a small sample of neurorehabilitation specialists. Further study on a larger sample of neurorehabilitation and neurological clinicians is needed to validate our results. Our questionnaire did not focus on different TMS modalities nor specific TMS risks, which might not help differentiate the lack of knowledge in different TMS applications and their safety. Our current study represents an essential first step toward assessing rehabilitation specialists’ general knowledge and attitudes toward TMS in Saudi Arabia.

Most rehabilitation specialists had insufficient knowledge of TMS, which was attributed to factors such as level of education. Therapists with higher education levels had higher knowledge scores than those with lower educational levels. A high educational level, years of experience, and availability of TMS equipment in the workplace led to a positive attitude toward TMS among rehabilitation specialists.