15 SA JournAl of PhySiotherAPy 2011 Vol 67 no 3 Research Article Description of physiotherapy services in a mental health institution in Nigeria Corresponding author: Caleb A. Gbiri Department of Physiotherapy, College of Medicine, University of Lagos, Idi­Araba, Lagos, Nigeria. Email: calebgbiri@yahoo.com; cgbiri@unilag.edu.ng AbSTrAcT: Physiotherapy has long been recognised as adjunct to drug therapy in the management of individuals with mental illness. however, little evidence existed on the utilization of physiotherapy in mental health especially in developing worlds. This study reviewed the utilization of physiotherapy in a Mental health Institution in lagos, nigeria and determined its contribution to quality of patient-care in the hospital. This study involved review of clients’ activity profile and patients’ record in a federal neuro-psychiatric hospital in lagos, nigeria between 2002 and 2006. The hospital records were used as source of information for socio- demographic details. Information on the physical diagnosis was extracted from the patients’ records in the departmental records. Data were summarized using descriptive statistics. Six thousand, four hundred and seventy-three (3.3%) out of the 195,686 patients of the hospital within the study period enjoyed physiotherapy ser vices. only 766 (14%) of the hospital in-patients enjoyed physiotherapy services. In addition, 808 clients enjoyed the health promotion services. low back pain (85; 21.7%), osteo-arthritis (82; 20.9%), stroke (64; 16.3%) and shoulder pain (29; 7.4%) were the most common co-existing health problems referred for physiotherapy. The importance of physiotherapy in mental health is evidenced in the number of patients/clients who benefited from its services. Therefore, physiotherapy is an integral and indispensible member of the mental health team. however, physiotherapy is still under-utilized in the hospital. This points to the need for proper integration of physiotherapy into mental health team in the hospital and other similar health institutions. Key wordS: phySIoTherApy ServIce, MenTAl heAlTh TeAM, MenTAl IllneSS, MenTAl heAlTh InSTITuTIon, nIgerIA. Gbiri CA1 Akinpelu AO2 Odole AC 2 1 Department of Physiotherapy, University of Lagos, Idi-Araba, Lagos, Nigeria. 2 Department of Physiotherapy, University of Ibadan, Ibadan, Nigeria. (Hare, 1986; Gbiri, 2007; 2011). How­ ever, it is unfortunate that physiotherapy is not usually part of mental health team in most of the mental health institu­ tions in Nigeria and Africa (Gbiri, 2007; 2011). Physiotherapy is not often utilized for individual with mental illnesses in Nigeria hospitals. There are 35 health institutions with mental health facili­ ties in Nigeria. However, only two not have physiotherapist in their mental­ health team. The Federal Neuro­Psychiatric Hos­ pital, Lagos was the first to integrate physiotherapy into its mental health team in Nigeria. The services include health promotion, management of co­ morbid health conditions amenable to physiotherapy, mental illness prevention and prevention of complication of drug therapy. Establishment of physiotherapy within the mental health institution has made the treatment of the patients who INtRODuCtION Mentally ill individuals often present with co­existing health conditions ame­ liorable to physiotherapy (Gbiri, 2007; 2011a). Poor treatment outcomes and high relapse rate have been major clini­ cal problems confronting mental health clinicians and researchers (Longabaugh et al, 1996; Lawal et al, 1999; Nierman and Lyons, 2001; Lawal et al, 2004). However inter­disciplinary and trans­ disciplinary approach reduces this men­ ace (Gbiri et al, 2011). It has long been recognised that physiotherapy for indi­ viduals with inorganic mental illness in form of exercise therapy/training and relaxation instruction is as effective as drug without the side effects (Hare, 1986; Gbiri et al, 2011). Stress manage­ ment/coping mechanisms and health promotion offered by physiothera­ pist are important in prevention and management of some mental illnesses were hitherto referred to hospitals with physiotherapy services less cumber­ some. This has made communication and team approach to patient care possi­ ble. The in­patients participate in physi­ cal exercises/training either as a form of treatment or as diversional therapy. Obesity and body weight increase are often one of the common complications of anti­psychotic drugs (Gbiri, 2011). Patients require physiotherapy to reduce the resultant accumulated weight and maintain ideal weight. Physical exercises 16 SA JournAl of PhySiotherAPy 2011 Vol 67 no 3 are also used to reduce stress, inactiv­ ity and boredom in patients with mental illness, and increase cardio­pulmonary fitness and mental alertness. Exercises are also used to engage the drug abuse patient and also as an anti­craving modality. However, exercise therapy has not been well utilized for patients in this hospital. This may partly due to the fact that decision to participate in exercise therapy is either left on the interest of the patient, who does not know its benefits or in the hands of the nurses’ in­charge who may not have had enough knowl­ edge on the effects and benefits of exer­ cise therapy in mental illness. The clients in the hospital are those that come for health promotion, stress management and prevention of men­ tal illness. They participate in stress manage ment and health promotion ses­ sions to prevent occurrence/resurgence or emergence of mental health disorder. Various exercises, massage and relaxa­ tion are designed to meet the individual need. It has long been realised that some of the skills that the physiothera­ pist has to offer in the areas of exercise therapy and relaxation instruction are as effective as drug without the commonly observed side effects (Hare, 1986; Gbiri, 2007; 2011). Diversional therapy in form of exercises and games are common phenomena in the management of indi­ vidual with mental illness in the hospi­ tal. This has not also been well utilized in this hospital. This may due to the fact that physiotherapists do not often contribute to decision making during admission of new patients. Individua­ lized physical exercises may reduce the effect of loneliness in depressed individual when taken routinely and meticulously (Gbiri, 2007; 2011). This is usually programmed for the period when the activity of the patient is low. It may also be taken concurrently with chemo­ therapy. These exercises are always of low intensity, low frequency with mild to moderate duration depending on indi­ vidual’s need and capability. Despite the various assumed benefits of physiotherapy to either prevent or ameliorate health problems in men­ tally ill individuals, there is dearth of literature on the contribution of physio­ therapy to mental health both in Nigeria and other parts of the world. Therefore, this study examined physiotherapy services and determined its contribution to quality of patient­care in the Federal Neuro­Psychiatric Hospital, Yaba, Lagos, Nigeria between January 2002 and December 2006. MEtHOD The study was approved by the Ethical Committee of Federal Neuro­Psychiatric Hospital, Yaba, Lagos, Nigeria. A list of all patients who were attended to in Federal Neuro­Psychiatric Hospital, Yaba, Lagos, Nigeria between January 2002 and December 2006 was compiled from the central hospital registers and the physiotherapy department patients’ register. The hospital file of each patient within the study period was thoroughly reviewed to obtain demographic infor­ mation (gender and age) and details about the diagnosis. The files of patients who were not properly registered were excluded. The patients were then sub­ divided on the basis of in­patients and out­patients. Bio­data of the patients’ were extracted from the records in the central hospital register. The information of whether they were referred for phy­ siotherapy was also extracted. Then the information on those who were referred for physiotherapy was then compared with the physiotherapy departmental patients’ record for those that actually received physiotherapy services. Data was summarised using frequency and percentage. Table 1: In-Patient and Out-Patient Attendance for Physiotherapy Services between January 2002 and December 2006 Year Age IN-PATIENTS OUT-PATIENTS (Years) Male % Male Female % Female ToTAl Male % Male Female % Female ToTAl GRouND ToTAl 2002 ≤ 19 2 50.0 2 50.0 4 ___ ___ ___ ___ _______ 4 ≥ 20 36.6 45 45 63.4 71 723 72.2 279 27.8 1002 1073 2003 ≤ 19 5 71.4 2 29.6 7 ___ ___ ___ ___ _______ 7 ≥ 20 40 58.8 28 41.2 68 746 67.6 351 32.4 1097 1145 2004 ≤ 19 11 78.6 3 21.4 14 ___ ___ ___ ___ _______ 14 ≥ 20 29 48.3 31 51.7 60 565 56.9 428 43.1 993 1558 2005 ≤ 19 7 70.0 3 30.0 10 ___ ___ ___ ___ _______ 10 ≥ 20 20 51.3 19 48.7 39 789 70.9 324 29.1 1113 1902 2006 ≤ 19 7 58.3 5 41.7 12 ___ ___ ___ ___ ______ 7 ≥ 20 28 66.7 14 33.2 42 764 62.8 452 37.8 1216 1980 TOTAL 155 50.5 152 49.5 307 3587 66.2 1834 33.8 4421 7928 17 SA JournAl of PhySiotherAPy 2011 Vol 67 no 3 Table 2: Attendance at the Stress Management and Health Promotion Clinics between January 2002 and December 2006 Year Age Group Male % Male Female % Female ToTAl 2002 ≤ 19 ___ ___ ___ ___ ___ ≥ 20 95 41.5 134 58.5 229 2003 ≤ 19 ___ ___ ___ ___ ___ ≥ 20 89 41.8 124 58.2 213 2004 ≤ 19 ___ ___ ___ ___ ___ ≥ 20 70 43.5 91 56.5 161 2005 ≤ 19 ___ ___ ___ ___ ___ ≥ 20 52 43.0 69 57.0 121 2006 ≤ 19 ___ ___ ___ ___ ___ ≥ 20 38 45.2 46 54.8 84 TOTAL 344 42.6 464 57.4 808 Table 3: Co-Morbid Conditions for which Individuals with Mental Illness are referred for Physiotherapy Services in the Hospital Condition 2002 2003 2004 2005 2006 ToTAl Low back pain 15 15 14 9 11 64 Stroke 7 7 13 9 14 50 Neuropathy ___ 1 ___ ___ ___ 1 Knee(s) Arthritis 18 19 13 10 5 65 Hand Injuries 1 1 4 2 3 11 Nerve Injuries ___ 4 ___ ___ ___ 4 Ankle/Foot Injuries 1 2 ___ ___ ___ 3 Faecal Incontinence 1 1 ___ ___ ___ 2 Monoparesis 3 ___ ___ ___ 1 4 Shoulder Pain 7 3 4 4 6 24 Paraplegia/paresis 2 3 ___ 2 ___ 7 Quadriplegia/ paresis 4 4 ___ 1 ___ 9 Incordination ___ 1 ___ ___ ___ 1 Cerebral Palsy 3 6 10 9 9 37 Cervical Spondylosis 9 4 ___ ___ ___ 13 Knee Stiffness 1 1 ___ ___ ___ 2 Erb’s Palsy 1 1 ___ ___ ___ 2 TOTALl 73 73 58 46 49 299 RESultS Of the 195 686 patients who attended the hospital between January 2002 and December 2006, 6473 (3.3%) enjoyed physiotherapy services. Five thousand four hundred and seventy­one (2.7%) were inpatients while 93.3% were out­ patients. Seven hundred and sixty­six (14.0%) inpatients received physio­ therapy. Out of the 190, 215 outpatients, 180, 479 (94.88%) were between 18 years and older. Majority (94.5%) of the patients on outpatient physio therapy were above 20 years of age. More female (55.5%) participated in the stress management and health promo­ tion (Table 2). More female (55.5%) participated in the stress management and health promotion sessions (Table 2). Eight hundred and eight (15.3%) of the physiotherapy patients/clients partic­ ipated in stress management and health promotion. The most common co­morbid health problems commonly referred for physi­ otherapy were low back pain, knee arthritis, stroke, cerebral palsy, shoulder injury and nerve injuries respectively (Table 3). The most common co­exist­ ing health problems referred for physio­ therapy are low back pain (85; 21.7%), knee osteo­arthritis (82; 20.9%), stroke (64; 16.3%) and shoulder pain (29; 7.4%). Patients who did not present with physical disability or neuro­muscular problems were not referred for physio­ therapy despite having mobility and postural problem that required physio­ therapy. Majority (82.5%) of the patients had inorganic psychosis including mild to moderate depression, anxiety, anger and eating disorders while 8.5% were referred due to complications from the treatment of organic psychotic illnesses. DISCuSSION Musculoskeletal injuries are not uncommon with mentally ill individual (Gbiri, 2007; 2011). These injuries occur indifferent ways including those sus­ tained during restlessness/hyperactivi­ ties, substance abuse (for the injectables) or sometimes during restrain (Gbiri, 2007; 2011). Conditions like back pain, shoulder pain and injuries, arthritis, neuritis, sciatica, nerve injuries and musculo­skeletal injuries often affect 18 SA JournAl of PhySiotherAPy 2011 Vol 67 no 3 intervention and recovery in indivi­ duals with mentally illness (Gbiri, 2007; 2011). Some mentally ill individuals are often bound to physically restrain the patient and forcefully brought into the hospital for therapy, especially the aggressive and violent ones. Some were restrained in either spiritual homes or traditional healing centres before ortho­ dox medical intervention. The conse­ quential neuro­muscular injuries are referred for physio therapy (Gbiri, 2007; 2011). These injuries pose confusion to psychiatrist in the effective manage­ ment of this group of patients because of choice of drug to avoid drug­drug interaction and complications. The involvement of physiotherapy in manage ment of the neuro­muscular problems and pain go a long way in reducing drug­drug interactions. Joint degenerative disorders and neuro­muscular injuries are the most commonly reported co­morbid condi­ tions in the participants for this study. Some patients also present stroke with neurological problems and cognitive impairments. The experience of the authors shows that the inter­occurrence of these two neurological disorders pose lots problems for effective reha­ bilitation programme. These patients lack the ability to follow simple instruc­ tion during rehabilitation due to cogni­ tive impairment secondary to either the stroke or the mental illness or both. Therefore, well­planned and meticu­ lously monitored physical exercises with adequate knowledge and experi­ ence in neurology and mental illness could be an antidote to this problem. Physiotherapeutic modalities are also used to reduce pain and stress in an indi­ vidual who abuses substances thereby improving habit resenting and modulate the brain rewarding system, thereby reducing dependency, and increase post­ discharged abstinence rate and relapse (Gbiri, 2007; 2011). This is useful in developing where substance abuse is increasing (Rounsaville, 1986; Lurigio and Lewis, 1989; Lawal et al, 1999; Lawal et al, 2004; Ayorinde et al, 2004). It is however unfortunate that none of these drug and substance abuse patients have been referred for physiotherapy for any of these purposes. This is because that well designed therapy between the psychiatrists who has the primary responsibility to the patients’ conditions and physiotherapists who will provide the adjunct therapy has not been well planned and tried. CONCluSION AND RECOMMENDAtIONS The importance of physiotherapy in mental health is evidenced in the number of patients/clients who benefited from its services. Therefore, physio­ therapy is an integral and indispen sible member of the mental health team. However, physiotherapy is still under­ utilized in the hospital. This points to the need for proper integration of physiotherapy into mental health team in the hospital and other similar health institutions. REfERENCES Ayorinde O, Gureje O, Lawal R 2004 Psychiatric research in Nigeria: Bridging tradition and modernisation. BJP. 184: 536­538. Gbiri CA 2007. Stress, mental­health and quality of life. Presented at 7th Health Round Table (HEART 7) organised by Emzor Pharmaceutical Limited. Gbiri CA 2011. Physiotherapy in mental illness. A workshop organized by the Department of Physiotherapy, Faculty of Health Sciences, College Medicine, Nnamdi Azikwe University. Gbiri CA, Badru, FA, Ladapo HTO and Gbiri AA 2011 Socio­Economic Correlates of Relapsed Admitted Patients in Nigeria mental health insti­ tution. International Journal of Psychiatry in Clinical Practice 15: 19­26. Hare M. 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