Physiotherapy Management of Upper Limb Dysfunction Following Stroke in Kinshasa, DR Congo

Abstract

Stroke is the leading cause of acquired disability in sub-Saharan Africa, with upper limb impairment affecting 70–80% of survivors. While the dose–response relationship in post-stroke rehabilitation has been well established in high-income countries, the factors that may modify this relationship in resource-limited settings, particularly the confounding effects of depression and environmental barriers, have never been formally investigated. This study aimed to describe the profile of post-stroke upper limb physiotherapy management in Kinshasa, compare functional outcomes according to the timing and intensity of rehabilitation, and determine whether the dose–response relationship is confounded by depressive symptoms and environmental barriers. A cross-sectional analytical study was conducted among 138 participants (90–180 days post-stroke) recruited from four rehabilitation centers in Kinshasa. The findings revealed that only 16.7% of participants initiated physiotherapy within the first week after stroke, while 93.5% received three sessions per week, corresponding to only 40% of the minimum recommended rehabilitation dose. Systematic upper limb–focused rehabilitation was reported in only 2.9% of cases. Patients who initiated rehabilitation early achieved a significantly higher median Action Research Arm Test (ARAT) score than those with delayed rehabilitation (50 [35–54] vs. 11 [0–28]; p < 0.0001; r = 0.468). Likewise, participants receiving high-intensity rehabilitation had significantly better ARAT scores than those receiving low-intensity rehabilitation (32 [13–50] vs. 5 [0–13]; p < 0.0001; r = 0.528). Although the correlation between the number of rehabilitation sessions and ARAT score was strong (ρ = 0.656; p < 0.0001), the regression coefficient (β) decreased by 55.7% after adjustment. Depressive symptoms, measured using the PHQ-2 (β = −4.031; p < 0.0001), and environmental barriers (β = −0.560; p = 0.002) remained significant independent predictors of functional recovery. These findings demonstrate that post-stroke physiotherapy in Kinshasa remains structurally suboptimal: 83.3% of patients initiate rehabilitation late, the effective rehabilitation dose represents only 40% of the recommended minimum, and the dose–response relationship is substantially confounded by depression and environmental barriers. These findings demonstrate that post-stroke physiotherapy in Kinshasa remains structurally suboptimal: 83.3% of patients initiate rehabilitation late, the effective rehabilitation dose represents only 40% of the recommended minimum, and the dose–response relationship is substantially confounded by depression and environmental barriers. Three major priorities therefore emerge: systematic early referral for rehabilitation, routine screening and management of depression as a prerequisite for optimal rehabilitation outcomes, and the development of a national rehabilitation protocol incorporating structured home-based exercise programs.