Predictors of Short Term Functional Outcomes of Stroke Patients Admitted to Saint Pauls Hospital Millennium Medical College Addis Ababa Ethiopia A Prospective Cohort Study

Clinics of Neurology Predictors of Short-Term Functional Outcomes of Stroke Patients Admitted to Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia: A Prospective Cohort Study. *Corresponding Author: Mohammed Kedir Shukri, Tsion Haile Woldemariam, Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia. Email: [email protected] , [email protected]. Received: 10-July-2025, Manuscript No. CONR - 4982 ; Editor Assigned: 12-July-2025 ; Reviewed: 24-July-2025, QC No. CONR - 4982 ; Published: 07-August-2025, DOI: 10.52338/conr.2025.4982. Citation: Mohammed Kedir Shukri, Tsion Haile Woldemariam. Predictors of Short-Term Functional Outcomes of Stroke Patients Admitted to Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia: A Prospective Cohort Study. Clinics of Neurology. 2025 August; 12(1). doi: 10.52338/conr.2025.4982. Copyright © 2025 Mohammed Kedir Shukri, Tsion Haile Woldemariam. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ISSN 2836-256X Research Article Mohammed Kedir Shukri 1 , Tsion Haile Woldemariam 5 , Betelhem Molla Dumessa 1 , Esmael Mohammed Dawud 1 , Yishak Abrham Bosha 2 , Weys Nesru Neda 3 , Abdurrhman Kedir Hamza 4 , Mihiret Legese Nadew 1 . 1 Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia. 2 Wolaita Sodo university, Wolaita Sodo, Ethiopia. 3 Uppsala University, Uppsala, Sweden. 4 Addis Ababa University, Addis Ababa, Ethiopia. 5 Arbaminch University College of Medicine and Health Sciences, Arbaminch, Ethiopia. www.directivepublications.org Abstract Background: Stroke is a leading cause of adult disability worldwide, with motor impairments such as hemiparesis significantly reducing quality of life. Identifying clinical and sociodemographic predictors of short-term functional recovery is essential to optimize rehabilitation strategies, especially in resource-limited settings like Ethiopia. Objective: To identify predictors of short-term functional outcomes among stroke patients admitted to Saint Paul’s Hospital Millennium Medical College from May 1 to October 30, 2023. Methods: This prospective cohort study enrolled 152 consecutive adult stroke patients confirmed by clinical and radiological criteria. Functional recovery was assessed at three weeks post-stroke using the Functional Independence Measure (FIM). Data on demographics, stroke characteristics, comorbidities, physiotherapy care (enrolment, timing, intensity), and hospital service factors were collected. Bivariate and multivariate logistic regression analyses identified independent predictors of functional improvement. Results: Among participants, 39.5% received physiotherapy during hospitalization. Physiotherapy enrolment was strongly associated with improved short-term functional recovery (adjusted odds ratio [AOR] = 5.36; 95% confidence interval [CI], 4.50–10.75; p = 0.006). Greater physiotherapy intensity (total hours) also predicted better outcomes (AOR = 1.35; 95% CI, 1.17–1.56; p < 0.001). Older age, presence of comorbidities, and in-hospital complications were negatively associated with recovery. Timing of physiotherapy initiation was not significantly linked to outcomes. Conclusion: Physiotherapy enrolment and intensity are key determinants of short-term functional recovery after stroke. Expanding access and ensuring adequate rehabilitation dosage should be prioritized in stroke care protocols in Ethiopia. Keywords : Stroke, Functional outcome, Physiotherapy, Rehabilitation, Ethiopia. INTRODUCTION Stroke remains a major cause of adult disability globally, accounting for approximately 11% of deaths and a leading contributor to long-term neurological impairment [1, 2]. In Ethiopia and other low- and middle-income countries (LMICs), the burden is rising due to increasing prevalence of risk factors such as hypertension, diabetes mellitus, and sedentary lifestyles, compounded by limited access to comprehensive stroke care and rehabilitation services [3]. Motor impairments, especially hemiparesis, are common after stroke and severely limit mobility and independence in activities of daily living (ADLs), impacting patients’ quality of life and social participation [4]. Functional recovery during the early post-stroke period is a critical determinant of long-term prognosis and quality of life [5, 6]. Rehabilitation, particularly physiotherapy, is essential to promote motor recovery, prevent secondary complications, and facilitate reintegration into the community. Evidence from high-resource settings indicates that early initiation

Directive Publications Mohammed Kedir Shukri, Tsion Haile Woldemariam and adequate intensity of physiotherapy improve functional independence and reduce disability [7, 8]. However, in Ethiopia, rehabilitation services are often limited by resource constraints, staffing shortages, and lack of standardized protocols. Multiple factors influence stroke recovery trajectories, including patient age, stroke severity, comorbidities, and in-hospital complications [9, 10]. Identifying predictors of functional outcomes in the Ethiopian context is crucial to tailor rehabilitation interventions and improve patient care. This study aimed to evaluate predictors of short-term functional outcomes among stroke patients admitted to Saint Paul’s Hospital Millennium Medical College, focusing on the role of physiotherapy care and individual clinical factors during the first three weeks post-stroke. The findings will inform evidence-based rehabilitation protocols and policy development in Ethiopia. METHODS Study Design and Setting This prospective cohort study was conducted at Saint Paul’s Hospital Millennium Medical College (SPHMMC), a tertiary referral hospital in Addis Ababa, Ethiopia. The hospital’s Internal Medicine Department includes a neurology unit with a dedicated stroke ward and an on-site rehabilitation center staffed by specialized physiotherapists and nurses. Study Period Data were collected from May 1 to October 30, 2023. Population - Source population: All adult patients admitted to the medical wards of SPHMMC during the study period. - Study population: All newly diagnosed stroke patients admitted to SPHMMC who met eligibility criteria. Eligibility Criteria - Inclusion: Adults aged ≥18 years with clinically and radiologically confirmed ischemic or hemorrhagic stroke. - Exclusion: Patients with pre-stroke disability (modified Rankin Scale >2), those transferred from other facilities >48 hours after stroke onset, and patients with severe cognitive impairment assessed using the Mini-Mental State Examination (MMSE) score <18, precluding informed consent or reliable functional assessment. Sample Size Determination and Sampling Technique A total of 152 consecutive eligible stroke patients were enrolled until the sample size was reached. Consecutive sampling minimized selection bias. Data Collection Tools and Techniques A pilot study validated the use of the Functional Independence Measure (FIM) in the local context. Data were collected using structured checklists covering sociodemographic variables, stroke characteristics, admission NIH Stroke Scale (NIHSS) scores, comorbidities, physiotherapy care details (enrolment, timing, intensity), and hospital service factors. Eight internal medicine residents, trained in a two-hour session on standardized assessment and data recording, collected data. Supervisors ensured data completeness and consistency. Functional recovery was assessed at discharge or three weeks post-stroke during outpatient follow-up. For patients hospitalized beyond three weeks, assessment was conducted as inpatients. Variables Independent variables: Age, sex, educational status; comorbidities (diabetes mellitus, hypertension, heart failure, dyslipidemia, chronic kidney disease); stroke type (ischemic or hemorrhagic), location (cortical or subcortical); stroke severity (NIHSS score); sensory loss; physiotherapy enrolment; physiotherapy intensity (total hours/session); timing of physiotherapy initiation. Dependent variable: Functional recovery measured by change in FIM score at three weeks post-stroke. Outcome Measures Stroke severity: NIHSS score categorized as minor (1–4), moderate (5–15), and moderate to severe (>15). Functional outcome: FIM total score (range 18–126), with higher scores indicating greater independence. A significant improvement was defined as a meaningful increase in FIM score leading to functional independence (>108). Data Processing and Analysis Data were entered and analyzed using SPSS v26. Descriptive statistics summarized baseline characteristics. Associations between predictors and functional outcomes were assessed with chi-square tests for categorical variables and independent t-tests for continuous variables. Variables with p < 0.20 in bivariate analysis were included in multivariate binary logistic regression to identify independent predictors of functional improvement. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported. Statistical significance was set at p < 0.05. Missing data were minimal (<5%) and handled using listwise deletion. Ethical Considerations The SPHMMC Institutional Review Board approved the study. Written informed consent was obtained from all participants or their caregivers. Confidentiality was maintained throughout. Page - 2Open Access, Volume 12 , 2025

Mohammed Kedir Shukri, Tsion Haile Woldemariam Directive Publications RESULT Participant Characteristics Among 152 stroke patients, 72 (47.4%) were male and 80 (52.6%) female. The mean age was 63.0 ± 15.85 years (range 25–89). Sociodemographic characteristics and physiotherapy enrolment are summarized in Table 1. Males had higher physiotherapy enrolment (44%) than females (35%). Enrolment varied by residence, highest among Oromia residents (57.1%) and lowest among Amhara (11.1%). Educational status influenced enrolment; inidividuals with a college degree had the highest participation rate (55%), while those with no formal education had the lowest (26.1%). Table 1. Sociodemographic characteristics and physiotherapy enrolment of the study participants. Variables Categories

Enrolment in Physiotherapy care Yes (%) No (%) Sex Male 32(44%) 40(55.6%) Female 28(35%) 52(65%) Address Addis Ababa 26(33.3%) 52(66.7%) Oromia 24(57.1%) 18(42.9%) Amhara 2(11.1%) 16(88.9%) Tigray 2(33.3%) 4(66.7%) Others 6(75%) 2(25%) Educational Status Primary school 10(29.4%) 24(70.6%) High school 16(50%) 16(50%) College degree 22(55%) 18(45%) No formal education 12(26.1%) 34(73.9%) Clinical Characteristics and Physiotherapy Enrolment Patients without comorbidities were more likely to receive physiotherapy (63.3%) compared to those with comorbidities (23.9%). Ischemic stroke patients had higher enrolment (46.3%) than hemorrhagic stroke patients (31.4%). Stroke severity influenced enrolment: 47.2% of mild, 43.8% of moderate, and 25% of severe cases were enrolled. Absence of sensory impairment was associated with higher enrolment (44.7% vs. 31%). Mean admission FIM score was 67.66 ± 27.08, indicating moderate functional status (Table 2). Table 2. Clinical Characteristics and Physiotherapy Enrolment of study participants. Variables Categories

Enrolment in physiotherapy Yes (%) No (%) Presence of comorbidities Yes 22(23.9%) 70(76.1%) No 38(63.3%) 22(36.7%) Stroke Types Ischemic 38(46.3%) 44(53.7%) Hemorrhagic 22(31.4%) 48(68.6%) Stoke Localization Cortical 34(39.5%) 50(60.5%) Subcortical 26(39.4%) 40(60.6%) NIHSS at admission Mild 34(47.2%) 38(52.8%) Moderate 14(43.8%) 18(56.3%) Severe 12(25%) 36(75%) Sensory Impairment Yes 18(31%) 40(69%) No 42(44.7%) 52(55.3%) FIM Score at admission Mean(SD) 67.66(SD: 27.084) FIM: Functional Independence measure NIHSS: Nation Institute of Health Stroke Scale SD: Standard Deviation Page - 3Open Access, Volume 12 , 2025

Mohammed Kedir Shukri, Tsion Haile Woldemariam Directive Publications Physiotherapy Care and Hospital Services Only 39.5% (n=60) of patients received physiotherapy during hospitalization. Timing of initiation was delayed; only 6.6% started within 48 hours, 18.4% between 48 hours and 7 days, and 10.5% after 10 days. A majority (60.5%) did not receive inpatient physiotherapy. Hospital physiotherapy service availability was reported by 31.6%, but only 1.3% experienced regular service provision. Mean total physiotherapy duration was 1.50 ± 6.03 hours. Average inpatient stay was 10.99 ± 5.48 days (Table 3). Medical treatments administered included anti-ischemic therapy (35.5%), antihypertensive agents (39.5%), anticoagulation (7.9%), and combined treatments (17.1%). In-hospital complications were common, with pneumonia affecting 40.3% of patients, followed by upper gastrointestinal bleeding (17.9%), venous thromboembolism (10.4%), acute kidney injury (9.0%), urinary tract infections (6.0%), and other complications (16.4%). Table 3. Physiotherapy care and other treatment related factors. Variables Categories Frequency Percentage (%) Physiotherapy care enrolment Enrolled 60 39.5 Not-enrolled 92 60.5 Timing of initiation of physiotherapy Within 48hrs 10 6.58 48hrs- 7 days 28 18.4 7 days- 10 days 6 3.9 After 10 days 16 10.5 Not received as inpatient 92 60.5 Physiotherapy service of the hospital Availability of the service48 31.6 Regularity of the service 2 1.3 Medical treatments received Anti-ischemic 54 35.5 Antihypertensive 60 39.5 Anticoagulation 12 7.89 Combined treatments 26 17.1 In hospital complications developed Pneumonia 61 40.3 Urinary tract infections 9 6.0 Acute Kidney Injury 14 9.0 Venous thromboembolism 16 10.4 UGIB 27 17.9 Others 25 16.4 Total hours of physiotherapy receivedMean(SD) 1.50 hours (6.031) Length of stay as an inpatient Mean(SD) 10.99 days (SD 5.483) Functional Outcomes At three weeks, mean FIM score improved to 71.05 ± 30.97. The change ranged from –6 to +14 points. Forty percent of patients reached high functional independence (FIM > 80). Forty-three percent showed statistically significant functional improvement (Figure 1). Page - 4Open Access, Volume 12 , 2025

Mohammed Kedir Shukri, Tsion Haile Woldemariam Directive Publications Figure 1. The result of functional status in the third week. Mean-71.05, SD-30.968 N= 152 Predictors of Functional Recovery Multivariate logistic regression identified physiotherapy enrolment (AOR = 5.36; 95% CI, 4.50–10.75; p = 0.006) and physiotherapy intensity (AOR = 1.35; 95% CI, 1.17–1.56; p < 0.001) as significant positive predictors of functional recovery. Older age was negatively associated with recovery (AOR = 0.94; 95% CI, 0.88–1.00; p = 0.048). Presence of comorbidities (AOR = 0.05; 95% CI, 0.004–0.53; p = 0.013) and in-hospital complications (AOR = 0.003; 95% CI, 0.000–0.049; p < 0.001) were strongly negatively associated. Stroke type, stroke localization, sex, NIHSS score, timing of physiotherapy initiation, medical treatments, and length of stay were not significantly associated after adjustment (Tables 4 and 5). Table 4. Association of predictive factors with functional recovery in short-term (FIM score change at third week) Variables

Categories

Significant FIM score change achieved COR (95% CI)P valueAOR (95%CI)P value Yes No Sex Male 40 32 1.222-6.5980.707 Female 26 54 Stroke types Ischemic 46 36 1.225-8.3280.016 0.127-14.1840.419 Hemorrhagic 20 50 Stroke localizationCortical 34 52 0.278-1.7370.435 Sub-cortical 32 34 Sensory impairment Yes 16 42 0.124-0.9070.029 0.003-5.0540.272 No 50 44 Baseline comorbidities Yes 18 74 0.019-0.1930.000 0.004-0.5270.013 No 48 12 Psychological preparedness Yes 34 50 0.276-1.7370.453 No 34 34 Enrollment in physiotherapy Yes 38 22 1.493-10.4410.005 4.499-10.7450.006 No 28 62 In-hospital complications Yes 2 70 0.001-0.0600.000 0000-0.049 0.000 No 64 16 Page - 5Open Access, Volume 12 , 2025

Mohammed Kedir Shukri, Tsion Haile Woldemariam Directive Publications Timing of initiation of physiotherapy <48hours 10 0.037-2.9100.574 48hours-7days28 7days-10days 6 >10days 16 Medical treatments received Anti-Ischemic54 0.211-2.9980.936 Anti-HTN 60 Anticoagulant12 Combined 26 FIM: Functional independence measure, COR: crude odds ratio, AOR: adjusted odds ratio, CI: confidence interval, SD: standard deviation, Anti- HTN: Anti-hypertensive Table 5. Association of predictive factors with functional recovery in short-term (FIM score change at third week) Variables Mean (SD) AOR (95%CI) P value Age 63 (15.85) 0.877-1.000 0.040 NIHSS at admission 13.54 (13.633) 0.905-1.076 0.761 The initial hour of the visit to the ED21.92 (24.175) 0.951-1.016 0.299 Total physiotherapy hours 4.92 (6.031) 1.169-1.1564 0.000 Length of stay in hospital 10.99 (5.483) 0.768-1.031 0.120 FIM: Functional independence measure, AOR: adjusted odds ratio, CI: confidence interval. ER: Emergency department SD: standard deviation Page - 6Open Access, Volume 12 , 2025 DISCUSSION This study highlights the critical role of physiotherapy enrolment and intensity in enhancing short-term functional recovery among stroke patients in Ethiopia. Despite physiotherapy’s proven benefits, only 39.5% of patients received inpatient physiotherapy, with very few starting within 48 hours. This low enrolment and delayed initiation likely reflect systemic barriers such as limited staffing, resource constraints, and lack of standardized rehabilitation protocols common in LMICs [11-13]. The strong positive association between physiotherapy intensity and recovery underscores the need to not only expand access but also ensure adequate session frequency and duration to maximize patient outcomes [14-16]. The absence of a significant association between timing of initiation and recovery may be due to the small proportion receiving early therapy and insufficient power to detect differences [17, 18]. Sociodemographic disparities in physiotherapy enrolment suggest inequities in access potentially driven by socioeconomic status, health literacy, and geographic proximity to services [19,20]. Clinical selection bias may favor patients with milder strokes and fewer comorbidities for rehabilitation [21, 22], highlighting the need for inclusive rehabilitation policies. Older age, comorbidities, and in-hospital complications were negatively associated with recovery, consistent with literature indicating these factors hinder post-stroke rehabilitation [23-26]. These findings emphasize the importance of comprehensive management of comorbid conditions and prevention of complications during acute care. Limitations include the single-center design and modest sample size, which may limit generalizability. The observational design precludes causal inference, and unmeasured confounders may exist. CONCLUSION Physiotherapy enrolment and intensity are key determinants of short-term functional recovery after stroke. To improve outcomes, Ethiopian stroke care protocols should prioritize expanding physiotherapy services, ensuring early and adequate rehabilitation dosing, and addressing sociodemographic and clinical disparities. Comprehensive management of comorbidities and prevention of complications are also essential to optimize recovery. Declarations Consent for publication Not applicable Availability of data and material The data collected for this study can be obtained from the first author based on a reasonable request. Competing interests No, I declare that the authors have no competing interests. Funding The data collection process for this study was funded by Saint Paul’s Hospital Millennium Medical College. The funding body only monitored the process to confirm whether the allocated funds were used for the proposed research.

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