Given the well-researched benefits of post-stroke rehabilitation in time and cost-constrained settings of health care, this study investigated the role of physiotherapy in the LOS of stroke patients in a tertiary hospital in south-west Nigeria, in terms of differences in the LOS of patients referred for physiotherapy and those who were not, as well as the correlations between the LOS, days of referral and utilization of physiotherapy.
The inpatient mortality rate was 40.7% for the 10 years reviewed. This finding is consistent with a previous study that showed that the mortality rate of stroke patients in Nigeria is high, ranging from 21 to 45% [11]. The distribution of the patients in this study, more males than females, is consistent with the findings of Njoku et al. [12] which showed that stroke is commoner in males. Furthermore, the male sex has been listed as a risk factor for stroke [13]. The mean age of stroke patients in this study (61.4 ± 14.10 years) resonated with what is found in the literature that age is a non-modifiable risk factor for stroke, increasing with each age from the fifth decade of life [14]. Although the incidence and prevalence of stroke in Nigeria have been reported to be on the increase [15] the number of cases seen per year appeared to fluctuate in our study. This fluctuation may be attributed to the various industrial actions in the country’s health sector during the different years of the study, most notably in 2013 and 2015, when multiple healthcare associations and unions were on strike [16]. This affected the admission of patients into the facility during these periods.
The LOS of stroke patients admitted in the hospital was higher than those from studies conducted in developed countries such as the USA, where LOS is less than 7 days for most stroke patients [17]. In Australia, LOS varies between 4.2 and 17.5 days, depending on the health facility of admission [18]. However, the result of this study is comparable to the findings of Desalu et al. [8] and Olaleye et al. [9] who reported the length of stay of stroke patients to be 16 days and 12 days respectively in other health facilities in south-west Nigeria. Bearing in mind that physiotherapy is provided only for patients referred by physicians in Nigeria, the referral rate of 80.7% observed for stroke patients in the study facility was high. This may suggest that the physicians in this facility were aware of the benefits of physiotherapy in improving functional recovery and independence after a stroke. However, this study showed a moderate positive correlation between the LOS and the time of referral for physiotherapy. Some clinical practice guidelines [19, 20] have recommended a period between 24 to 48 h within the onset of a stroke for the commencement of physiotherapy. However, this depends on the severity of the stroke among patients and varies with institutions and physicians.
The clinical pattern of patients in this study is consistent with clinical deficits seen in stroke; all patients in the records had at least one neurological deficit. A finding validated by the fact that stroke itself is a rapidly developing focal loss of cerebral function [21]. Therefore, the motor and sensory impairments lasting more than 24 h due to cerebral vascular disruption only corroborate the diagnosis of the pathology. A higher percentage of the patients in this study had a left-sided stroke, and this result is consistent with findings by Portegies et al. [22] that left-sided strokes are often more reported by clinicians. This study also found that ischemic stroke was the most frequently seen type of stroke during the study period. This pattern is consistent with findings in other studies [8, 23].
Our results showed differences between the LOS of patients referred for physiotherapy and those not referred, and also between patients who utilized physiotherapy and those who did not. For patients who received physiotherapy, conventional treatments [24] such as positioning, range of motion exercises, balance/postural training, mobility training, task-oriented therapy, prescription and training using assistive devices, patients, and caregivers’ education were administered daily until discharge. Patients who were referred for physiotherapy and utilized physiotherapy stayed longer in the hospital than those who were not referred or those who did not utilize physiotherapy. There was also a positive correlation between LOS and time of referral for physiotherapy. The longer the time of referral, the longer the patients stay in the hospital. This finding is comparable to a study by Hartley et al., who concluded that early physiotherapy input is associated with reduced LOS [25]. Some factors that may have contributed to the longer time of referral for these patients are delay in referral, the workup for diagnostic tests, the period of waiting for results of requested investigations before referring patients, and inefficient communication between the various health professionals, in this case, the physician and the physiotherapist [6, 7]. It might also be that the patients that stayed longer had more severe symptoms of stroke [26] that required more physiotherapy services.
Our study found no difference in the LOS between patients with right side affectation and those with the left side affected but found a difference in LOS between stroke types. Similar to our findings, a study by Somotun et al. [3] showed that patients with ischemic strokes have a slightly higher LOS than those with hemorrhagic stroke. However, contrary to their results, we found that patients with unspecified stroke types had a longer LOS than those with ischemic or hemorrhagic strokes. This finding may be attributed to a longer time spent scheduling and making payments for required investigations, carrying out case reviews, and sending intra- and interdisciplinary referrals to make accurate diagnoses and deliver best management practices to this category of patients.
The utilization of physiotherapy was low regarding the average number of sessions received by individual patients (an average of five physiotherapy sessions throughout inpatient admission). An average of 7 days was recorded before physiotherapy was commenced for patients who utilized physiotherapy. Also, more than a quarter of the patients referred for physiotherapy did not utilize the services. These may be attributed to the fact that referrals for physiotherapy come at a cost, and considering the poor financial situations of many patients in a developing country, the patients referred might not have been able to afford the fees for physiotherapy services after paying several other hospitalization bills, especially as many patients do not have any health insurance. Only about 5% of Nigerians are registered in the National Health Insurance Scheme (NHIS) [27]. Furthermore, we found a weak positive correlation between the LOS and utilization of physiotherapy in this study. These findings could have contributed to the longer LOS observed for patients in our study. Murie-Fernandez et al. [28] reported that prompt commencement of physiotherapy combined with a focus on the right intensity and required duration led to better functional outcomes with reduced length of stay and mortality rates. Also, in terms of utilization, a systematic review [29] has shown that extra physiotherapy can reduce the length of stay for adults with acute and sub-acute conditions, including stroke.
The complications documented for the stroke patients in this study are commonly described in the literature [30]. However, these did not include other common ones, such as falls [31]. This may suggests that not all complications were documented. Insufficient documentation of stroke complications might have contributed to the longer LOS. However, it could also be that these patients were not ambulating or moving out of bed, or did so under thorough supervision by health professionals. The presence of complications in stroke patients in this study is low compared to previously reported percentages in the acute phase of stroke [32]. Indredavik et al. listed pain and other complications such as urinary tract infection and pneumonia on stroke admissions as medical complications [32]. These complications were not found in the medical records included in our study, implying that these complications were not encountered or reported. In our study, patients with complications stayed longer in the hospital than patients without complications, although we found a weak correlation between LOS and the number of complications. Yet, complications have generally been found to prolong the discharge of patients from health facilities since more time is dedicated to treating and monitoring the patient during conservative management [33, 34].
This study had limitations, especially the difficulty experienced in obtaining specific information from patients’ case notes due to the available documentation. Also, the LOS was not categorized into separate intervals. Significantly, the unavailability of the specific diagnosis for some patients was why some information such as type of stroke was not recorded for all patients. Hence, some types of stroke had to be assigned to the category of “unspecified”. Also, the general use of “hemorrhagic stroke” is contained in the patients’ case files. We suggest that future studies that utilize regression analysis may be useful to determine the predictors of shorter LOS among stroke patients. Similarly, studies that examine the relationship between specific clinical diagnosis of stroke and length of stay can be carried out to improve understanding between these variables.
