Utilization of physiotherapy in the continuum of stroke care at a tertiary hospital in Ibadan , Nigeria

Objectives: To investigate the pattern of referral for and utilisation of physiotherapy in the continuum of stroke care at a tertiary hospital in Ibadan, Nigeria. Methods: Referral notes and medical records of patients admitted in the University College Hospital, Ibadan with a clinical diagnosis of stroke between January, 2009 and December, 2013 were retrospectively reviewed. Information on age, sex, type of stroke, length of hospital stay, referral for physiotherapy and utilisation of physiotherapy were retrieved. Data were summarised using descriptive statistics and analysed using Chi-square test. Results: A total of 783 patients with stroke were admitted in the hospital during the period under study. The in-patient mortality rate was 37.2%. The mean Length of Hospital Stay (LoHS) was 16.17±12.34 days. Referral rate for physiotherapy was high (75.8%) and the mean time from admission to referral for physiotherapy was three days. Majority of patients referred utilised physiotherapy (63.4%) and mean number of physiotherapy sessions received during in-patient care was 8.69±6.45. There was a significant association between LoHS and utilisation of in-patientphysiotherapy (p=0.02). Conclusion: The referral rate of stroke patients for physiotherapy was relatively high. Utilisation of in-patient physiotherapy reduced length of hospital stay among patients with stroke. Utilisation of out-patient physiotherapy was low. Strategies to enhance out-patient utilisation should be explored.


Introduction
Stroke is a major public health problem, and a leading cause of adult disability and Disability Adjusted Life Years (DALY) loss 1,2 in low and middle income countries.Prevention and effective rehabilitation strategies are paramount to reducing the burden of stroke.Rehabilitation following a stroke begins during the acute phase of hospitalization as soon as the diagnosis of stroke is established and life-threatening problems are under control 3,4 .Early initiation of rehabilitation procedures can enhance return of neurological function, reduce stroke-related disability, improve long term outcome and quality of life among stroke patient 5,6,7 .Effective rehabilitation requires multidisciplinary team approach 8 .Physiotherapy, a key component of stroke rehabilitation 9 focuses on the recovery of physical function for stroke survivors 10,11,12 and plays a positive role in enhancing independent living 13 .Immediate and intensive physiotherapy after a stroke has been associated with reduction in morbidity and mortality and improvement in performing activities of daily living 14,15 .Bernhardt et al 16 identified physiotherapists as important drivers of mobility in the acute phase of stroke care.In fact, early mobilization and functional training provided by physiotherapists were considered the most important aspect of acute treatment in a Stroke Unit 17 .Therefore, timely access to physiotherapy is valuable to the persons concerned, their families and society as a whole 15 .
Physician referrals are required for stroke survivors to access physiotherapy services in Nigeria, a factor which increases the time from stroke onset to initiation of physiotherapy intervention.Although, the effectiveness of physiotherapy in stroke rehabilitation has been proven 18 and physiotherapist's assessment of a stroke patient with-in the first 72 hours of admission is considered one of the indicators of effective stroke care 8 , evidence has suggested that physicians' use of physiotherapy services may be suboptimal 19,20 .Several factors have been postulated for this low level of utilisation of physiotherapy among physicians.These include poor communication between physiotherapists and physicians; doubt about the effectiveness and indications for physiotherapy treatment as well as low level of knowledge and awareness of the scope of physiotherapy among physicians [21][22][23][24] .
The importance and utilisation of physiotherapy in the continuum of stroke care have been studied in different countries 25,26,27 Most of these studies were conducted in high income countries.It is inappropriate to generalise studies on utilisationof physiotherapy from a high income country to a low resourced country due to differences in therapeutic procedures and socio-economic strata.There is a dearth of studies evaluating the pattern of referral for physiotherapy after stroke in Nigeria and the proportion of stroke patients who actually utilised this service is unclear.Therefore, this study was conducted to investigate the pattern of referral and utilisation of physiotherapy in the continuum of stroke care in the foremost teaching hospital in Nigeria.Investigating the pattern of referral for physiotherapy services maybe the first step in identifying the extent to which physicians adhere to Clinical Practice Guidelines for the management of patients with stroke.Examining the level of utilisation may help determine if access to physiotherapy is equitable among stroke patients.This may guide healthcare policy makers on the need to adopt and implement best practices in the management of stroke patients for better treatment outcomes.

Methods
This retrospective study was conducted using data from the health records of stroke patients admitted in the University College Hospital (UCH), Ibadan, Nigeria.The hospital is the premier teaching hospital in Nigeria and government-designated centre of excellence in neurosciences.Ethical approval was obtained from the appropriate Institutional Health Research Ethics Committee.All cases of stroke admitted in the hospital between January 2009 and December 2013 were identified from the hospital's records.The records indicated the patients' outcome as either deceased or discharged home alive.Case files of patients who survived their stroke event were subsequently retrieved and reviewed regardless of the cause of stroke.Case files of patients who died while on admission were excluded from the review for pattern of referral for and utilisation of physiotherapy.Other sources of data used for information retrieval were the physiotherapy referral cards and physiotherapy attendance register of the stroke survivors.Referral cards are given to patients by the referring physicians and are kept as part of the patients' record in the physiotherapy department.Physiotherapy attendance registers are used for both in-patients and out-patients.The registers document the number of times the physiotherapists had contact with the patients.They are used alongside documentations on the physiotherapy treatment received by the patients in the patients' case files for quality control.Physiotherapy intervention for patients with stroke at the University College Hospital is targeted at improving muscle strength and extensibility in the affected extremities, relieving pain and spasticity where present, improving cardiovascular fitness and enhancing functional independence.This is achieved through the use of specific therapeutic exercises ranging from passive to assisted active to free active and resisted active exercises; static and dynamic balance retraining exercises; task specific functional exercises and gait retraining.Information on the socio-demographic and clinical characteristics of the patients, date of onset of stroke, length of hospital stay, referral for physiotherapy, date of referral for physiotherapy, date physiotherapy commenced, number of physiotherapy sessions during in-patient care and the date out-patient physiotherapy commenced were extracted from the data sources into a data sheet.Each patient's identification number in the patients' record was encrypted for privacy and protection.

Data analysis
Descriptive statistics of mean, percentages and proportion were used to summarize the socio-demographic and clinical characteristics of stroke survivors managed at the UCH between January 2009 and December 2013.Referral for physiotherapy was based on a documented plan to refer for physiotherapy in patient's case file and its corresponding physiotherapy referral card.It was recorded as a 'Yes' or 'No'.Utilisation was based on documented evidence of a physiotherapy assessment after referral.Number of physiotherapy session was the number of documented contacts between the physiotherapist and the patients.Chi square test was used to examine the re-African Health Sciences Vol 17 Issue 1, March, 2017 lationship among socio-demographic and clinical characteristics of patients, length of hospital stay and each of pattern of referral for and utilisation of physiotherapy.Level of significance was set at 0.05.

Results
A total of 783 patients with stroke made up of 397 (50.7%) males and 386 (49.3%) females, were admitted in the University College Hospital (UCH), Ibadan between January, 2009 and December, 2013.There was a steady increase in stroke incidence from 8.3% in 2009 to 30.9% in 2012.There was a 5.9% decrease in the rate of admission between 2012 and 2013 (Figure 1).Less than two-thirds (62.8%) of the stroke patients admitted in the hospital survived the stroke event giving an in-patient mortality rate of 37.2% for the period studied.
Survival was slightly higher among female patients (50.4%).Out of the 492 (62.8%) identified stroke survivors, the case files of only 306 (62.2%) patients could be retrieved for review.The identified records were reviewed and categorized on the basis of referral for physiotherapy and utilisation of physiotherapy during and after in-patient care (Figure 2).Data was extracted from the medical records (case files and physiotherapy attendance registers) of 306 stroke survivors.The mean age of the stroke survivors was 59.9±13.0 years (median = 60.0years).129 (42.2%) of them were aged 65 years and above (Table 1).Majori-ty of the patients (55.9%) had no documentation on the type of stroke.The ratio of ischaemic to haemorrhagic stroke was approximately 5:3 in those for which it was documented.The risk factors for stroke in majority of the patients were hypertension (67.4%), followed by hypertension coexisting with diabetes (23.0%).The mean length of hospital stay for the stroke survivors was 16.2±12.3days (median = 13days).232 patients out of a total of 306 patients were referred for physiotherapy while on admission amounting to an in-patient referral rate of 75.8% over the five year period (Table 2).

(median 6).
There was no significant association (p > 0.05) between length of hospital stay and each of patients' age and sex.However, there was an observed age-related increase in length of hospital stay.More than a quarter (28.0%) of the patients above 65 years of age stayed in the hospital beyond three weeks while less than a fifth (18.6%) of those below 45 years of age stayed in the hospital for the same duration.There was no significant association (>0.05) between utilisation of in-patient physiotherapy and each of age, sex and stroke type (Table 3).However, a significant association was observed between length of hospital stay and utilisation of physiotherapy (p = 0.02).The length of hospital stay was shortest among patients who utilised physiotherapy most (63.9%) while it was longest (>6 weeks) in patients with the lowest rate of utilisation.

Discussion
This study examined the proportion of stroke patients admitted in a tertiary hospital referred for physiotherapy and the proportion that utilised physiotherapy.The results showed an increasing incidence of stroke during the study period.Evidence has shown an increasing incidence and prevalence of stroke in Nigeria 28,29 .The slight dip observed in 2013 may be due to the incessant industrial action in the health sector in the country that year.Though stroke incidence in the study population cut across the 3 rd to 8 th decade of life, the median age of the patients reviewed was 60 years.This is in congruence with previous findings age remains a non-modifiable and most important singular risk factor for stroke.This risk increases with each successive decade above age 55 years 30,31 .Our findings suggest that the incidence of stroke is slightly higher in males than females based on the proportion of male patients admitted on account of stroke compared to females which is consistent with findings from previous studies 32,33,34 .However, survival was higher among females than males resulting in a tilt in favour offemales at discharge.The severity of stroke for male and female participants in this study could not be ascertained.
It is probable that males suffered worse stroke than females.Furthermore, there could be variation in premorbid status and prevalence of comorbidities between male and female stroke patients in this study.It has been postulated that co-morbidities can compromise recovery from a stroke 35 .Therefore, inferences on sex differences in survival rate among the stroke patients in this study must be drawn with caution.
About three-quarters of the stroke survivors were referred for physiotherapy.This is a rather high proportion of stroke patients admitted in the hospital.Physiotherapy is not provided routinely for patients in Nigeria because of the need for physician referral.The high referral rate found in this study suggests that physicians are aware of the importance of physiotherapy in improving functional independence post-stroke.It could also be a reflection of the level of adherence of physicians in this hospital to recommended clinical practice guidelines that stroke pa-tients be referred for physiotherapy as soon as life-threatening problems are under control.Evidence indicates that patients do better with a well-organized, multidisciplinary approach to post-acute rehabilitation after a stroke 36 .This multi-disciplinary approach to stroke rehabilitation includes physiotherapy.There is a wide variation in the time between patients' admission to the hospital and initiation of physiotherapy.Most clinical practice guidelines suggest 24 hours post stroke onset.It should be noted that life-threatening problems vary in severity among patients and practice settings.This may contribute to the delay in referral of stroke patients in this hospital.
Only about two-thirds of the patients referred for physiotherapy actually received physiotherapy.This is comparable to findings in literature about utilisation of physiotherapy 26,37 .McKevitt et al 26 and Leemrijse et al 37 reported utilisation rates of 70.7% and 69.0%respectively for physiotherapy.However, Lee et al 27 in a similar study reported a utilisation rate of 33% for physiotherapy in acute stroke.This is rather low compared to the findings of this study.The findings of Lee and colleagues 27 may be related to the reported dearth of physiotherapists and consequent rationing of rehabilitation services in Taiwan.Although the physiotherapist to population ratio in Nigeria is worse at 1:42,000, the utilisation rate was higher and comparable with utilisation in countries with high physiotherapists to patient ratio.This suggests that non-availability or dearth of physiotherapists all by itself has minimal effect on utilisation of physiotherapy.
In comparison to the referral rate, the number of treatment recipients is somewhat low.Physiotherapy intervention after stroke is often long-term and considered expensive in Nigeria.This may account for the underutilisation.When patients are initially admitted into hospital they enjoy a lot of social and financial support.This support system dwindles as the illness becomes protracted and patients oftentimes are out of funds by the time they are referred for physiotherapy and might therefore not be able to afford the service.Moreover, most patients had no health insurance coverage and were expected to pay for their treatment out of pocket.In addition, inadequate information on the importance of physiotherapy in motor recovery post stroke among the patients may affect their choices.Many would rather spend money on drugs and investigations than pay for physiotherapy services.Utilisation was higher among elderly stroke survivors.Research has demonstrated an association between increasing age African Health Sciences Vol 17 Issue 1, March, 2017 and provision of physiotherapy after stroke 26 .This could be because the elderly tend to have worse stroke in view of possible age-related co-morbidity.It may also be that they tend to be referred more by physicians in order to avoid the complications of stroke which are likely to be higher and worse in this age group.
Length of hospital stay was shortest in patients with higher rate of utilisation.This suggests that stroke patients who received in-patient physiotherapy early recovered faster and got discharged earlier than those who did not.This is consistent with the results of an earlier study by Freburger 38 on utilisation of physiotherapy and outcomes of care for patients with stroke.This is likely due to the proven benefit of physiotherapy in improving/maximising function after a stroke.Early initiation of rehabilitation procedures can enable greater return of neurological function and improve long term outcome and quality of life in stroke patients 5,6,7 .Many of the immediate complications of stroke such as deep vein thrombosis, skin breakdown, contracture formation, constipation, and hypostatic pneumonia are related to immobility and are preventable with early mobilisation 6 .
Out-patient utilisation of physiotherapy was rather low compared to inpatient utilisation among the stroke patients.This is probably because the University College Hospital is a referral centre and patients come from different parts of the country to this foremost healthcare facility.It is likely that most of the patients had out-patient physiotherapy in other hospitals within their community.Underuse may also be a reflection of poor adherence to outpatient appointment schedule among the patients.It could also be that patients went for unorthodox treatment from traditional healers who are purported to have supernatural healing powers that can cure stroke.Future studies should explore reasons for this decrease in utilisation, and identify factors that may improve outpatient physiotherapy utilisation among stroke survivors in Ibadan, Nigeria.
There was no difference in physiotherapy utilisation based on age, sex and type of stroke.This is comparable to the report of Lee et al 27 that utilisation of inpatient rehabilitation for acute stroke was similar irrespective of patients' age, sex and year of onset.Redondo-Sendino et al 39 however, reported a higher healthcare utilisation among Spanish women compared to men.The fact that demographics were not related to utilisation may be an indication that physiotherapy utilisation for stroke patient in Ibadan, Nigeria is equitable though underused.Documentation inaccuracies and difficulty in verifying records may affect the pattern of referral and utilisation reported in this study.Records of patients who died during hospital admission were not reviewed.If these records were reviewed, the pattern of referral for and utilisation of physiotherapy among the patients could be different.
Comparison between severity of stroke and referral for and utilisation of physiotherapy could not be made because stroke severity was not documented consistently in an objective manner in these patients.

Conclusion
Referral rates of patient with stroke for physiotherapy are satisfactory.However, the rate of utilisation of physiotherapy among patients with stroke appears inadequate.Utilisation of physiotherapy during hospital admission is associated with reduced length of hospital stay among patients with stroke.Therefore, utilisation of physiotherapy among stroke patients should be encouraged for reduced length of hospital stay and improved functional outcome.Utilisation of out-patient physiotherapy was low.Strategies to enhance out-patient utilisation should be explored.

Figure 1 :
Figure 1: Trends in stroke incidence, survival rate, referral rate for physiotherapy and utilization of physiotherapy

Table 3 : Association among patients' profile and utilisation of physiotherapy (n = 147)
The referral rate was highest (81.1%) in year 2012 and lowest (71.4%) in 2010.Only about a third (35.3%) of the patients were referred for and assessed by physiotherapists within 24 hours of admission while 9.1% of patients were referred about a week or more post-admission.The mean length of time from admission to first physiotherapy assessment was 3.0±3.2days (median = 2.0 days).