Prevention, management, and rehabilitation of stroke in low- and middle-income countries

Human-robot interaction in motor imagery: A system based on the STFCN for unilateral upper limb rehabilitation assistance

BACKGROUND

Rehabilitation training based on the brain-computer interface of motor imagery (MI-BCI) can help restore the connection between the brain and movement. However, the performance of most popular MI-BCI system is coarse-level, which means that they are good at guiding the rehabilitation exercises of different parts of the body, but not for the individual component.

NEW METHODS

In this paper, we designed a fine-level MI-BCI system for unilateral upper limb rehabilitation assistance. Besides, due to the low discrimination of different sample classes in a single part, a classification algorithm called spatial-temporal filtering convolutional network (STFCN) was proposed that used spatial filtering and deep learning.

COMPARISON WITH EXISTING METHODS

Our STFCN outperforms popular methods in recent years using BCI IV 2a and 2b data sets.

RESULTS

To verify the effectiveness of our system, we recruited 6 volunteers and collected their data for a four-classification online experiments, resulting in an average accuracy of 62.7 %.

CONCLUSION

This fine-level MI-BCI system has good appli-cation prospects, and inspires more exploration of rehabilitation in a single part of the human body.

pRESET thrombectomy device outcomes in patients with acute ischemic stroke: A systematic review and meta-analysis

BACKGROUND

Many devices are used to perform mechanical thrombectomy in the setting of large vessel occlusion acute ischemic stroke. We sought to evaluate the efficacy and safety of pRESET stent-retriever systems.

METHODS

We conducted a comprehensive systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies up to March 2024 were retrieved from PubMed, Scopus, Web of Science, and Embase databases.

RESULTS

A total of 8 papers met the inclusion/exclusion criteria comprising a total of 1140 participants (average age 72.4 ± 11.9, female percentage (50%). Preintervention intravenous thrombolysis was utilized in 46.5% (range 32.9-65.4) of patients, with a median National Institute of Health Stroke Scale at presentation of 15 (range 0-38). The middle cerebral artery was the most commonly affected artery, with a prevalence of 76.4% (range 62.8-100). The pRESET stent-retriever systems demonstrated a first-passing effect rate of 53.4% [95% confidence interval [CI] 44.8; 61.7] and a final thrombolysis in cerebral infarction 2b-3 grade rate of 90.41% [95% CI 82.13; 95.08]. Ninety-day modified Rankin Scale (0-2) rate was 42.2% [95% CI 27.6; 58.4], and 90-day mortality rate was 15.1% [95% CI 9.8; 22.6]. Postintervention hemorrhage occurred at a rate of 28.6% [CI 17.2; 43.6].

CONCLUSION

Our systematic review and meta-analysis describes the efficacy of the pRESET stent retriever system in managing acute ischemic stroke patients. The pRESET device was found to have a similar safety and efficacy profile to other mechanical thrombectomy devices currently in use.

A Study on the Effects of a Self-Administered Eye Exercise Program on the Balance and Gait Ability of Chronic Stroke Patients: A Randomized Controlled Trial

This study investigates the effects of a self-administered eye exercise (SEE) program on the balance and gait ability of chronic stroke patients hospitalized due to hemiplegia. This study includes 42 patients diagnosed with stroke-related hemiplegia and hospitalized at D Rehabilitation Hospital. The researcher randomly allocated 42 patients into two groups: the experimental group (EG, n = 21, mean age = 58.14 ± 7.69 years, mean BMI = 22.83 ± 2.19 kg/m2) and the control group (CG, n = 21, mean age = 58.57 ± 6.53 years, mean BMI = 22.81 ± 2.36 kg/m2). The SEE program was applied to the EG and the general self-administered exercise (SE) program was applied to the CG. After 4 weeks of intervention, weight distribution of the affected side, the Timed Up and Go test (TUG), step length of the affected side, step length of the unaffected side, gait speed, and cadence were analyzed and compared. In the within-group comparison, both groups showed significant differences in weight distribution (p < 0.05), TUG (p < 0.05), step length of the affected side (p < 0.05), step length of the unaffected side (p < 0.05), gait speed (p < 0.05), and cadence (p < 0.05). In the between-group comparison, a significant difference in the TUG (p < 0.05) was observed. The SEE program had an overall similar effect to the SE program in improving the balance and gait ability of chronic stroke patients, and had a greater effect on dynamic balance ability. Therefore, the SEE program can be proposed as a self-administered exercise program to improve balance and gait ability in stroke patients who are too weak to perform the SE program in a clinical environment or have a high risk of falling.

Global burden of stroke attributable to high systolic blood pressure in 204 countries and territories, 1990-2019

Background

High systolic blood pressure (HSBP) is severely related to stroke, although the global burden of stroke associated with HSBP needs to be understood.

Materials and methods

Data derived from the Global Burden of Disease, Injuries, and Risk Factors Study were used to analyze deaths, disability-adjusted life years (DALYs), age-standardized rates of mortality (ASMR), age-standardized rates of DALY (ASDR), and estimated annual percentage change (EAPC).

Results

Globally, 52.57% of deaths and 55.54% of DALYs from stroke were attributable to HSBP in 2019, with higher levels in men; the ASMRs and ASDRs in 1990-2019 experienced a decline of 34.89% and 31.71%, respectively, with the highest ASMR- and ASDR-related EAPCs in women. The middle socio-demographic index (SDI) regions showed the most numbers of deaths and DALYs in 2019 and 1990, with a decline in ASMR and ASDR; East Asia shared over 33% of global deaths and DALYs; Central Asia shared the highest ASMR and ASDR; high-income Asia Pacific experienced the highest decline in the ASMR- and ASDR-related EAPCs. Central and Southeast Asia had the highest percentages for deaths and DALYs, respectively, with more ASMR in high-middle SDI; the SDI and human development index were negatively associated with ASMR/ASDR and ASMR/ASDR-related EAPCs in 2019.

Conclusion

Global deaths and DALYs of stroke attributable to HSBP but none of their age-standardized rates have been on the rise over the past three decades; its disease burden focused especially on men aged 70 years and older in East, Central, and Southeast Asia, and the middle to high SDI regions.

Cognitive evaluation and rehabilitation in high- and low-income countries

Starting from her own personal experience, in the First Part of the article, the author reconstructs how the specialized sectors of cognitive evaluation and rehabilitation evolved in Western countries (Europe, the United States, Canada, and Australia, in particular) during the second half of the last century and the first decades of this century. In the Second Part, she describes her personal experience in setting up a rehabilitation centre dedicated to traumatic brain-injured subjects and her commitment to international cooperation (Bolivia, Rwanda, Myanmar, Tanzania) in the field of cognitive evaluation and rehabilitation in favour of people with congenital and acquired cerebral pathology, especially in the paediatric age, since there is an almost total lack of diagnostic, but above all, rehabilitative procedures for cognitive functions in low-middle income countries. In the Third Part of the article, the author carries out an extensive review of the international literature on the differences in access to cognitive diagnostic evaluation and cognitive rehabilitation in middle- and low-income countries - but not only - underlining the urgent need to launch a major international collaborative effort to reduce and eliminate these discrepancies.

Mounting Stroke Crisis in India: A Systematic Review

Stroke, a neurological disorder, has emerged as a formidable health challenge in India, with its incidence on the rise. Increased risk factors, which also correlate with economic prosperity, are linked to this rise, including hypertension, diabetes, obesity, sedentary lifestyle, and alcohol intake. Particularly worrisome is the impact on young adults, a pivotal segment of India's workforce. Stroke encompasses various clinical subtypes and cerebrovascular disorders (CVDs), contributing to its multifaceted nature. Globally, stroke's escalating burden is concerning, affecting developing nations. To combat this trend effectively and advance prevention and treatment strategies, comprehensive and robust data on stroke prevalence and impact are urgently required. In India, these encompass individuals with elevated BMIs, and those afflicted by hypertension, diabetes, or a familial history of stroke. Disparities in stroke incidence and prevalence manifest across India, with differences in urban and rural settings, gender-based variations, and regional disparities. Early detection, dietary changes, effective risk factor management, and equitable access to stroke care are required to address this issue. Government initiatives, like the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) 2019, provide guidelines, but effective implementation and awareness campaigns are vital. Overcoming barriers to stroke care, especially in rural areas, calls for improved infrastructure, awareness campaigns, and support systems. Data standardization and comprehensive population studies are pivotal for informed public health policies.

Knowledge, Attitudes, and Practices Among Middle-Aged and Elderly Population Towards Ultrasound Screening for Strokes

Purpose

This study aimed to assess the knowledge, attitudes and practices (KAP) among middle-aged and elderly population towards ultrasound screening for strokes.

Patients and Methods

This web-based cross-sectional study was conducted between March, 2023, and May, 2023 at Shanghai Eighth People's Hospital. A self-designed questionnaire was developed to collect demographic information of middle-aged and elderly population and assess their knowledge, attitudes and practices toward ultrasound screening for strokes.

Results

A total of 552 participants enrolled in this study, among them 151 (27.36%) aged above 60 years old, 306 (55.43%) resided in rural area, 239 (43.30%) possessed educational attainment at the level of junior college, college or above. The mean knowledge, attitudes and practice scores were 5.53 ± 2.56, 40.22 ± 5.60 and 38.30 ± 7.38, respectively. Pearson's analysis was performed to assess the relationship between knowledge, attitudes, and practices. It was shown that knowledge and attitudes were positively correlated (r = 0.544, P < 0.001), and knowledge and practices were also positively correlated (r = 0.404, P < 0.001). Additionally, there was a positive correlation between attitude and practice scores (r = 0.566, P < 0.001).

Conclusion

The results of this study demonstrate that the middle-aged and elderly population exhibited insufficient knowledge, positive attitudes, and moderate practices towards ultrasound screening for strokes. There is a need to improve the understanding of stroke risk factors, symptoms, and emergency measures among this population.

Technology-Based Health Promotion Training Among Stroke Patients: A Randomized Controlled Trial

Stroke is a disease with a heavy social and familial care burden that can cause permanent brain damage, long-term disability, and/or death. This study aimed to determine the effect of technology-based health promotion training on the daily life activities, quality of life, and self-care of stroke patients. The study design was a Randomized Controlled Trial. The study sample included persons diagnosed with stroke diagnosed with stroke and were receiving inpatient treatment in the neurology clinic of a university hospital. The sample size was calculated as a total of 70 patients, 35 interventions and 35 controls. The intervention group patients received telephone-based education and follow-up grounded in Orem's Self-Care Theory over a 12-week period subsequent to their discharge. The educational content was divided into three distinct categories: self-care needs with regard to health deviations, developmental self-care needs, and universal self-care practices. Data were collected using the Montreal Cognitive Assessment Scale, the Katz Index of Independence in Activities of Daily Living, Stroke-Specific Quality of Life Scale, and the Exercise of Self-Care Agency Scale. The Independent Sample T-Test was used for intergroup comparisons, and the Dependent Sample T-Test was used for intragroup pre-test and post-test comparisons. Independent variables affecting the post-test scores, such as age and gender, were analyzed using the multiple linear regression model. The scale sub-dimension variables were compared using the multivariate analysis of variance test according to the groups. When compared with the control group patients after the training, it was determined that there was a statistically significant difference in the intervention group patients' mean scores for the Stroke-Specific Quality of Life Scale (t = 11.136, p = .001) and the Exercise of Self-Care Agency Scale (t = 14.358, p = .000). Training interventions led to enhanced awareness and knowledge about stroke among the intervention group patients. They also fostered the development of healthier lifestyle behaviors and bolstered both self-care abilities and quality of life.

Effect of a customized safety harness on movement kinematics in a dance-based exergaming among people with chronic stroke

BACKGROUND

Dance-based exergaming has exhibited efficacy in people with chronic stroke, it is beneficial to advance towards independent self-training to increase long-term compliance, and cost effectiveness through safety harness devices. Thus, the purpose of the study was to investigate people with chronic stroke's dance-movement kinematics to different types of assistance, namely no assistance, safety harness assistance, and contact guard assistance with gait belt.

METHODS

Community-dwelling people with chronic stroke (n = 10) participated in the study. Seven inertial sensors were used to capture their dance movements with three songs slow, medium, and fast pace. Three trials were recorded for each dance and the mean values of variables were used for analysis. A customized MATLAB code generated joint angle excursions (difference between the maximum and minimum angle peaks) of the hip, knee, and ankle in the sagittal plane.

FINDINGS

The results exhibited decreased joint angle excursions in no assistance condition in comparison to safety harness assistance and contact guard assistance conditions for all song paces (p < 0.05). The safety harness, and contact guard assistance condition exhibited similar levels of joint angle excursions for the all the conditions, except significantly higher hip (slow, and fast pace) (p < 0.05), and ankle (medium pace) (p < 0.05) joint angle excursions in contact guard assistance in comparison to safety harness assistance.

INTERPRETATION

The study represents the joint angle excursions that are influenced by different conditions in chronic stroke. Future studies, should evaluate feasibility of safety harness augmented dance-based exergaming in home-setting among chronic stroke.

Evaluation of a stroke rehabilitation training programme for community-based primary healthcare

Background

Family caregiver training is an integral part of stroke rehabilitation programmes and is associated with improved caregiver and stroke survivor outcomes. In the Cape Winelands District, a low-resourced rural community-based setting in South Africa, stroke survivors and family caregivers mostly rely on assistance from community health workers (CHWs), despite their lack of stroke-specific rehabilitation training.

Objectives

To evaluate the implementation and immediate effects of a bespoke, 16 session, 21 h stroke rehabilitation training programme for CHWs to better support family caregivers.

Methods

Two cooperative inquiry groups participated in participatory action research to design and develop the programme. This article reports on the implementation of this programme. Inquiry group members directly observed the training, obtained written and verbal feedback, interviewed CHWs and observed them in the community. Consensus on their learning was achieved after reflection on their experience and observations.

Results

Learning of the cooperative inquiry groups was categorised into the effect on community-based care, the training programme's design and development, how training was delivered and implications for service delivery. Community health workers empowered caregivers and stroke survivors and enabled access to care, continuity, coordination and person-centredness. The need for experiential learning and a spiral curriculum was confirmed. Therapists needed a different set of skills to deliver training. A systems approach and effective leadership were needed to enable community health workers to use their new skills.

Conclusion

The stroke rehabilitation training programme demonstrated potential for integration into service delivery and equipping CHWs to support family caregivers and stroke survivors. Further evaluation of the programme's effectiveness and scale-up is needed.

Contribution

Evidence of an intervention to train CHWs to support stroke survivors and family caregivers.

Spatiotemporal Trends of Stroke Burden Attributable to Ambient PM2.5 in 204 Countries and Territories, 1990-2019: A Global Analysis

BACKGROUND AND OBJECTIVES

Previous studies suggested that long-term exposure to ambient fine particulate matter (PM2.5) is associated with increased risk of stroke. However, limited studies evaluated the stroke burden attributable to ambient PM2.5 globally, especially comprising across different regions, countries, and social-economic levels. We thus conducted this study to estimate the spatial and temporal trends of ambient PM2.5-related stroke burden by sex, age, and subtypes from 1990 to 2019 at global, regional, and national levels.

METHODS

Information on the ambient PM2.5-related stroke burden from 1990 to 2019 was obtained from the Global Burden of Disease study 2019. The burdens of stroke attributable to ambient PM2.5 (i.e., age-standardized mortality rate [ASMR] and age-standardized disability-adjusted life-year rate [ASDR]) were estimated by sex, age, and subtypes from 1990 to 2019 at global, regional, and national levels. The estimated annual percentage change (EAPC) was used to evaluate the changing trends of ASDR and ASMR attributable to ambient PM2.5 from 1990 to 2019. The Spearman correlation coefficient was used to examine the correlation between sociodemographic index (SDI) and EAPC of ASMR and ASDR at the national level.

RESULTS

In 2019, the global ambient PM2.5-related stroke mortality and disability-adjusted life years were 1.14 million and 28.74 million, respectively, with the corresponding ASDR and ASMR of 348.1 and 14.3 per 100,000 population, respectively. The ASDR and ASMR increased with age and were highest among male patients, in the middle SDI regions, and for intracerebral hemorrhage (ICH). From 1990 to 2019, the absolute death number of stroke attributable to ambient PM2.5 and the corresponding ASMR and ASDR were both in an increasing trend. The corresponding EAPCs in ASMR and ASDR were 0.09 (95% CI -0.05 to 0.24) and 0.31 (95% CI 0.18-0.44), respectively. The significant increases of ASMR and ASDR were observed in the low, low-middle, and middle SDI regions, and for ICH. However, a decreasing trend was observed in high and middle-high SDI regions, and for subarachnoid hemorrhage.

DISCUSSION

The global burden of stroke attributable to ambient PM2.5 showed an increasing trend over the past 30 years, especially in male patients, low-income countries, and for ICH. Continued efforts on reducing the level of ambient PM2.5 are necessary to reduce the burden of stroke.

The burden of suspected strokes in uMgungundlovu - Can biomarkers aid prognostication?

Background

The burden of stroke is increasing worldwide. The hierarchical healthcare referral system in South Africa (SA) poses unique challenges to clinicians when caring for people with suspected strokes (PsS). To improve health outcomes, novel strategies are required to provide adequate care, including prognostication, in SA.

Aim

To determine the subjective burden of and challenges posed by suspected stroke cases and the potential usefulness of biomarkers in prognostication.

Setting

This study was conducted in the uMgungundlovu Health District (UHD), KwaZulu-Natal, SA.

Methods

An online questionnaire was distributed to doctors within the UHD. Demographic data and answers to a series of 5-point-Likert-type statements were collected.

Results

Seventy-seven responses were analysed. A third of doctors worked in primary healthcare facilities (PHCare) and saw ≥ 2.15 suspected strokes-per-doctor-per-week, compared to ≥ 1.38 seen by doctors working in higher levels of healthcare. Neuroimaging was relied upon by > 85% of doctors, with nearly half of PHCare doctors having to refer patients to facilities 5 km - 20 km away, with resultant delays. Knowledge about prognostic biomarkers in strokes was poor, yet most doctors believed that a biomarker would assist in the prognostication process and they would use it routinely.

Conclusion

Doctors in this study faced a significant burden of strokes and rely on neuroimaging to guide their management; however, many challenges exist in obtaining such imaging, especially in the PHCare setting. The need for prognostic biomarkers was clear.

Contribution

This research lays the platform for further studies to investigate prognostic biomarkers in stroke in our clinical setting.

A Bibliometric Analysis of Stroke Caregiver Research from 1989 to 2022

Many stroke survivors suffer with varying degrees of disability and require assistance. Family members commonly act as informal caregivers, caring for these stroke survivors and ensuring care adherence. However, many caregivers reported a poor quality of life and physical and psychological distress. Due to these issues, multiple studies have been conducted to understand the experience of caregivers, the outcomes of caregiving, and interventional studies among caregivers. This study aims to explore the intellectual landscape of studies on stroke caregivers using bibliometric analysis. Studies with "stroke" and "caregiver" terms in the title were extracted from the Web of Sciences (WOS) database. The resulting publications were analysed using the 'bibliometrix' package in R. There were 678 publications analysed, dating from 1989 to 2022. The USA has the highest number of publications (28.6%), followed by China (12.1%) and Canada (6.1%). The most productive institution, journal and author were The University of Toronto (9.5%), 'Topics in Stroke Rehabilitation' journal (5.8%) and Tamilyn Bakas (3.1%), respectively. Co-occurrences keywords analysis revealed mainstream research on stroke survivors, burden, quality of life, depression, care, and rehabilitation, reflecting the timeless hotspot in the field. This bibliometric analysis helps us understand the current state of stroke caregiver research and its recent developments. This study can be used to evaluate research policies and promote international cooperation.

Which factors affect the implementation of telerehabilitation? Study protocol for a mixed-methods systematic review with a framework synthesis

BACKGROUND

Telehealth approaches are promising for the delivery of rehabilitation services but may be under-used or under-implemented.

OBJECTIVE

To report a review protocol to identify how much telerehabilitation (telehealth approaches to the delivery of rehabilitation services) have been used and implemented, and which factors have affected such implementation.

METHODS

A mixed-methods systematic review with a framework synthesis. Six databases for the scientific literature will be searched, complemented by snowballing searches and additional references coming from key informants (i.e., rehabilitation researchers from a networking group in health services research). We will include English-language empirical research examining the routine use or implementation of telehealth technologies in physical rehabilitation services or by physical rehabilitation professionals from a range of study designs, excepting case studies, case reports, and qualitative studies with n < 5. Two independent reviewers will perform the screenings, quality appraisals (using the Joanna Briggs Institutes' appraisal checklists), and the data extractions. The Consolidated Framework for Implementation Research will be used to synthesize the data on the enablers and barriers of the implementation of telerehabilitation approaches. All the authors will be involved at this synthesis, and key informants will provide feedback.

CONCLUSION

The results can inform further implementation endeavours.

Ischemic stroke mortality and time for hospital arrival: analysis of the first 90 days

OBJECTIVE

To analyze the association between time of arrival at a reference hospital and mortality of people with ischemic stroke.

METHOD

Descriptive and inferential statistics were used. Modifying and confounding variables between time of arrival and mortality were observed in the multivariate analysis. The Akaike Information Criterion was used to choose the model. Statistical significance of 5% and risk correction using the Poisson Model were adopted.

RESULTS

Most participants arrived within 4.5 hours of symptom onset or wake up stroke to the referral hospital and 19.4% died. The score of the National Institute of Health Stroke Scale was a modifier. In the multivariate model stratified by scale score ≥14, arrival time >4.5h was associated with lower mortality; and age ≥60 years and having Atrial Fibrillation, to higher mortality. In the model stratified by score ≤13, previous Rankin ≥3, and presence of atrial fibrillation were predictors of mortality.

CONCLUSION

The relationship between time of arrival and mortality up to 90 days was modified by the National Institute of Health Stroke Scale. Prior Rankin ≥3, atrial fibrillation, time to arrival ≤4.5h, and age ≥60 years contributed to higher mortality.

Stroke systems of care in the Philippines: Addressing gaps and developing strategies

In the Philippines, the mortality from stroke during the last 10 years remains high. This paper aims to describe the gaps in stroke care and the development of stroke systems of care in the Philippines. Gaps in stroke systems of care include low number of neurologist, inadequate CT scan machines, lack of stroke training among health workers, lack of stroke protocols and pathways, poor community stroke awareness, low government insurance coverage with high out of pocket medical expenses, lack of infrastructure for EMS, inadequate acute stroke ready hospitals, stroke units and rehabilitation facilities. Although there are government programs for primary stroke prevention, the strategies are inadequate to address the stroke pandemic. The Stroke Society of the Philippines has worked with the government for nationwide and regional stroke training of health care workers, community stroke awareness, setting up acute stroke ready hospitals and acute stroke units in different areas of the country and adapting stroke protocols and pathways. Stroke registries are now utilized for quality improvement. Thrombolysis rate has improved from 1.4% in 2014-2016 to 11% in 2021 based on RES-Q database. Because of government subsidy, thrombolysis in the government hospitals is higher at 7.4% (range 4.4-16.9) compared to 4.8% (range 0-10.1) rate in private hospitals. Mechanical thrombectomy rate remained low at 0.4% of all acute ischemic stroke patients because of the cost. With limited resources, infrastructures for emergency medical service is lacking. The innovations done by other LMIC can be done in the Philippines including the use of technology to reach out to geographically isolated areas and use of mobile stroke units. Non neurologist can be trained to help treat stroke patients. Upgrading of the Philhealth insurance to cover for reperfusion therapies, adequate stroke infrastructures and network, and increase in community stroke awareness are areas for improvement in the Philippine stroke systems of care.

Post Hoc Subgroup Analysis of the BCause Study Assessing the Effect of AbobotulinumtoxinA on Post-Stroke Shoulder Pain in Adults

Botulinum toxin type A is approved for the focal treatment of spasticity; however, the effectiveness of abobotulinumtoxinA (aboBoNT-A) in patients with shoulder pain who have set reduced pain as a treatment goal is understudied. In addition, some patients encounter delays in accessing treatment programs; therefore, the suitability of aboBoNT-A for pain reduction in this population requires investigation. These factors were assessed in aboBoNT-A-naive Brazilian patients in a post hoc analysis of data from BCause, an observational, multicenter, prospective study (NCT02390206). Patients (N = 49, n = 25 female; mean (standard deviation) age of 60.3 (9.1) years; median (range) time since onset of spasticity of 16.1 (0-193) months) received aboBoNT-A injections to shoulder muscles in one or two treatment cycles (n = 47). Using goal attainment scaling (GAS), most patients achieved their goal of shoulder pain reduction after one treatment cycle (72.1%; 95% confidence interval: 57.2-83.4%). Improvements in GAS T-score from baseline, clinically meaningful reductions in pain score at movement, and clinically meaningful increases in passive shoulder abduction angle further improved with repeated treatment more than 4 months later, despite treatment starting at a median of 16.1 months after the onset of spasticity. These findings support the further investigation of aboBoNT-A injections in chronic post-stroke shoulder pain.

A meta-analysis of resveratrol protects against cerebral ischemia/reperfusion injury: Evidence from rats studies and insight into molecular mechanisms

Objective: To evaluate the neuroprotective effect of resveratrol (RES) in rat models of cerebral ischemia/reperfusion (I/R) injury.

Data sources: PubMed, Embase, MEDLINE, Cochrane Library, and Chinese databases were searched from their inception dates to July 2022. No language restriction was used in the literature search.

Date Selection: Studies were selected that RES were used to treat cerebral I/R injury in vivo. Two reviewers conducted literature screening, data extraction and methodological quality assessment independently.

Outcome measures: Cerebral infarct volume was included as primary outcome. The secondary outcomes included cerebral water content and neurological deficit scores. Malondialdehyde (MDA) and superoxide dismutase (SOD) were used to evaluate oxidative stress during medication.

Results: A total of 41 studies were included, and only a few of them the methodological quality was relatively low. Compared with the control group, RES significantly reduced the cerebral infarct volume (29 studies, standard mean difference (SMD) = −2.88 [−3.23 to −2.53], p < 0.00001) and brain water content (nine studies, MD = −9.49 [−13.58 to −5.40], p < 0.00001) after cerebral I/R injury, then neurological function was improved (15 studies, SMD = −1.96 [−2.26 to −1.65], p < 0.00001). The MDA level (six studies, SMD = −8.97 [−13.60 to −4.34], p = 0.0001) was decreased notably after treatment of RES, while the SOD level (five studies, SMD = 3.13 [−0.16 to 6.43], p = 0.06) was increased unsatisfactory. Consistently, subgroup analysis of cerebral infarct volume suggested that the optimal therapeutic dose is 30 mg/kg (eight studies, SMD = −5.83 [−7.63 to −4.04], p < 0.00001). Meanwhile, 60 min of occlusion (three studies, SMD = −10.89 [−16.35 to −5.42], p < 0.0001) could get maximum benefit from compared with 90 min and 120 min of occlusion. On the other hand, the publication bias cannot be ignored. The pharmacological mechanisms of RES on cerebral I/R injury models as reported have be summarized, which can be used for reference by researchers to further plan their future experiments.

Conclusion: RES might have a good neuroprotective effect on cerebral I/R injury in rats, then 30 mg/kg RES may be the optimal dose for treatment, and early administration of RES should be more neuroprotective. Also it need to be further verified through exploration of dose effect relationship, or delay administration or not.

Legal Implications of Stroke Biobanking and Genomics Research in Sub-Saharan Africa

Stroke is a major cause of death in Sub-Saharan Africa (SSA) and genetic factors appear to play a part. This has led to stroke biobanking and genomics research in SSA. Existing stroke studies have focused on causes, incidence rates, fatalities and effects. However, scant attention has been paid to the legal issues in stroke biobanking and genomics research in the sub-region. Therefore, this article examines the legal implications of stroke biobanking and genomics research in SSA. The article adopts a textual analysis of primary and secondary sources in law. It reports that there are laws from the perspectives of human right, the common law, and intellectual property. However, there are gaps to be filled. The article therefore argues for legislative intervention. It concludes that pending the time the statute will be enacted, genomics researchers in Africa should adopt the ethical guidelines prepared by Human Heredity and Health in Africa (H3 Africa).

Circulating Biomarkers in Long-Term Stroke Prognosis: A Scoping Review Focusing on the South African Setting

Cerebrovascular disease, including both ischaemic and haemorrhagic strokes, remains one of the highest causes of global morbidity and mortality. Developing nations, such as South Africa (SA), are affected disproportionately. Early identification of stroke patients at risk of poor clinical prognosis may result in improved outcomes. In addition to conventional neuroimaging, the role of predictive biomarkers has been shown to be important. Little data exist on their applicability within SA. This scoping review aimed to evaluate the currently available data pertaining to blood biomarkers that aid in the long-term prognostication of patients following stroke and its potential application in the South African setting. This scoping review followed a 6-stage process to identify and critically review currently available literature pertaining to prognostic biomarkers in stroke. An initial 1191 articles were identified and, following rigorous review, 41 articles were included for the purposes of the scoping review. A number of potential biomarkers were identified and grouped according to the function or origin of the marker. Although most biomarkers showed great prognostic potential, the cost and availability will likely limit their application within SA. The burden of stroke is increasing worldwide and appears to be affecting developing countries disproportionately. Access to neuroradiological services is not readily available in all settings and the addition of biomarkers to assist in the long-term prognostication of patients following a stroke can be of great clinical value. The cost and availability of many of the reviewed biomarkers will likely hinder their use in the South African setting.

The burden of stroke and its attributable risk factors in the Middle East and North Africa region, 1990-2019

Stroke is one of the leading causes of mortality and morbidity across the globe. Providing comprehensive data on the burden of stroke in the Middle East and North Africa (MENA) could be useful for health policy makers in the region. Therefore, this article reported the burden of stroke and its attributable risk factors between 1990 and 2019 by age, sex, type of stroke, and socio-demographic index. Data on the point prevalence, death, and disability-adjusted life-years (DALYs), due to stroke, were retrieved from the Global Burden of Disease study 2019 for the 21 countries located in the MENA region from 1990 to 2019. The counts and age-standardised rates (per 100,000) were presented, along with their corresponding 95% uncertainty intervals (UIs). In 2019, the regional age-standardised point prevalence and death rates of stroke were 1537.5 (95% UI: 1421.9–1659.9) and 87.7 (78.2–97.6) per 100,000, which represent a 0.5% (− 2.3 to 1.1) and 27.8% (− 35.4 to − 16) decrease since 1990, respectively. Moreover, the regional age-standardised DALY rate in 2019 was 1826.2 (1635.3–2026.2) per 100,000, a 32.0% (− 39.1 to − 23.3) decrease since 1990. In 2019, Afghanistan [3498.2 (2508.8–4500.4)] and Lebanon [752.9 (593.3–935.9)] had the highest and lowest age-standardised DALY rates, respectively. Regionally, the total number of stroke cases were highest in the 60–64 age group and was more prevalent in women in all age groups. In addition, there was a general negative association between SDI and the burden of stoke from 1990 to 2019. Also, in 2019, high systolic blood pressure [53.5%], high body mass index [39.4%] and ambient particulate air pollution [27.1%] made the three largest contributions to the burden of stroke in the MENA region. The stroke burden has decreased in the MENA region over the last three decades, although there are large inter-country differences. Preventive programs should be implemented which focus on metabolic risk factors, especially among older females in low SDI countries.

Population-based stroke incidence estimates in Peru: Exploratory results from the CRONICAS cohort study

BACKGROUND

Limited information exists about the incidence of first-ever stroke at the population level, particularly in low- and middle-income countries (LMIC). Longitudinal data from the CRONICAS Cohort Study includes both altitude and urbanization and allows a detailed assessment of stroke incidence in resource constrained settings. The aim of this study was to estimate the incidence and explore risk factors of first-ever stroke at the population level in Peru.

METHODS

Stroke was defined using a standardised approach based on information from cohort participants or family members. This information was adjudicated centrally by trained physicians using common definitions. Time of follow-up was calculated as the difference between date of enrolment and the reported date of the stroke event. Unstandardised and age-standardised, first-ever stroke incidence rate and 95% confidence intervals (95% CI) were calculated. Generalized linear models, assuming Poisson distribution and link log, were utilized to determine potential factors to develop stroke.

FINDINGS

3,601 individuals were originally enrolled in the cohort and 2,471 provided data for the longitudinal analysis. The median time of follow-up was 7.0 (range: 1 - 9) years, accruing a total of 17,308 person-years. During followup, there were 25 incident cases of stroke, resulting in an age-standardised incidence of stroke of 98.8 (95% CI: 63.8 - 154.0) per 100,000 person-years. After adjustment by age and sex, stroke incidence was higher among people with hypertension (incidence risk ratio (IRR) = 5.18; 95% CI: 1.89 - 14.16), but lower among people living at high altitude (IRR = 0.09; 95% CI: 0.01 - 0.63).

INTERPRETATION

Our results indicate a high incidence of first-ever strokes in Peruvian general population. These results are consistent with the estimates found in previous LMIC reports. Our study also found a contributing role of hypertension, increasing the risk of having a first-ever stroke. This work further advances the field of stroke epidemiology by identifying high altitude as a factor related to lower incidence of stroke in a longitudinal study. However, this information needs to be considered with cautions because of the study limitations.

Burden of depression and predictors among Ethiopian stroke survivors: Cross-sectional study

BACKGROUND

stroke is a common cause of mortality and morbidity in low- and middle-income countries. It is a very sudden episode in the patients' lives and can lead to multiple psychosocial, social, and economic consequences, and psychiatric problems. poststroke depression is the most common and major neuropsychiatric consequence of stroke that affects one-third of stroke survivors. The aim of this study to assess the burden of depression and its predictors among stroke survivors with local version validated Patient Health Questionnaire.

METHODS

An institutional-based cross-sectional study was conducted among stroke patients at selected tertiary level hospitals. Data were collected by interview method using structured questionnaires, and patient medical record reviews and data were recruited by using consecutive sampling method. Bivariate and multivariable binary logistic regression model analysis was used with SPSS version 23 to identify factors associated with depression.

RESULTS

A total of one hundred eighty stroke patients participated in the study with a response rate of 88.2%. The overall prevalence of depression is 49.6% (95% CI: 42.8, 56.7). Occupation, marital status, level of education of stroke patients was significantly associated with post stroke depression with P < 0.05.

CONCLUSION

The study findings presented that nearly half of the stroke patients suffered from post stroke depression. Post-stroke depression was strongly associated with patient occupation, marital status, and level of education There is urgent need for integration of screening for and management of post-stroke depression among stroke survivors.

The burden of stroke and modifiable risk factors in Ethiopia: A systemic review and meta-analysis

BACKGROUND

The burden and contribution of modifiable risk factors of stroke in Ethiopia are unclear. Knowledge about this burden and modifying risk factors is pivotal for establishing stroke prevention strategies. In recent decades, the issue of lifestyle and behavioral modification is a key to improve the quality of life. The modifiable risk factors are an importance as intervention strategies aimed at reducing these factors can subsequently reduce the risk of stroke. So far, many primary studies were conducted to estimate the burden of stroke and modifiable risk factors in Ethiopia. However, the lack of a nationwide study that determines the overall pooled estimation of burden and modifiable risk factors of stroke is a research gap.

METHODS

To conduct this systemic review and meta-analysis, we are following the PRISMA checklist. Three authors searched and extracted the data from the CINAHL (EBSCO), MEDLINE (via Ovid), PubMed, EMcare, African Journals Online (AJOL), and Google scholar. The quality of the primary study was assessed using the Newcastle-Ottawa Scale (NOS) by two independent reviewers. The primary studies with low and moderate risk of bias were included in the final analysis. The authors presented the pooled estimated burden of stroke and its modifiable risk factors. The registered protocol number in PROSPERO was CRD42020221906.

RESULTS

In this study, the pooled burden of hemorrhagic and ischemic stroke were 46.42% (95%CI: 41.82-51.53; I2 = 91.6%) and 51.40% (95%CI: 46.97-55.82; I2 = 85.5%) respectively. The overall magnitude of modifiable risk factor of hypertension, alcohol consumption and dyslipidemia among stroke patients were 49% (95%CI: 43.59, 54.41), 24.96% (95CI%:15.01, 34.90), and 20.99% (95%CI: 11.10, 30.88), respectively. The least proportion of stroke recovery was in the Oromia region (67.38 (95%CI: 41.60-93.17; I2 = 98.1%). Farther more, the proportion of stroke recovery was decreased after 2017 (70.50 (56.80-84.20).

CONCLUSIONS

In our study, more than 90% of stroke patients had one or more modifiable risk factors. All identified modifiable stroke risk factors are major public health issues in Ethiopia. Therefore, strategy is designed for stroke prevention to decrease stroke burden through targeted modification of a single risk factor, or a cluster of multiple risk factors, used on a population, community, or individual level.

Preparedness for caregiving moderates the association between burden and health-related quality of life among family caregivers of stroke patients in Nigeria

Studies on improving the health-related quality of life of stroke patients are abundant, but less attention has been given to the factors influencing the wellbeing of their family caregivers, especially in low- to middle-income countries such as Nigeria where the burden of stroke is expected to increase. In this study, we examined the moderating role of preparedness for caregiving in the connection between the burden of caregiving and health-related quality of life of family caregivers of stroke patients in Nigeria. Family caregivers of stroke patients (140 females and 60 males; aged between 18 and 57 years) were purposively sampled from a Federal Medical Center in Southeastern Nigeria. Participants completed measures of caregiver’s strain (burden), health-related quality of life, and preparedness to give care. Results showed that burden negatively predicted physical health (β = –.61, CI: [–.89, –.34]) and mental health (β = –.76, CI: [−1.07, –.45]) dimensions of the health-related quality of life, respectively. Results also showed that preparedness moderated the relationship between burden and physical health (β = .21, CI: [.11, .32]), as well as mental health (β = .24, CI: [.12, .35]) dimensions. Ensuring that caregivers of stroke patients are adequately prepared to give care could ameliorate the negative impacts of caregiving on health of family caregivers of stroke patients.

Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Regularly updated data on stroke and its pathological types, including data on their incidence, prevalence, mortality, disability, risk factors, and epidemiological trends, are important for evidence-based stroke care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) aims to provide a standardised and comprehensive measurement of these metrics at global, regional, and national levels.

METHODS

We applied GBD 2019 analytical tools to calculate stroke incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and the population attributable fraction (PAF) of DALYs (with corresponding 95% uncertainty intervals [UIs]) associated with 19 risk factors, for 204 countries and territories from 1990 to 2019. These estimates were provided for ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and all strokes combined, and stratified by sex, age group, and World Bank country income level.

FINDINGS

In 2019, there were 12·2 million (95% UI 11·0-13·6) incident cases of stroke, 101 million (93·2-111) prevalent cases of stroke, 143 million (133-153) DALYs due to stroke, and 6·55 million (6·00-7·02) deaths from stroke. Globally, stroke remained the second-leading cause of death (11·6% [10·8-12·2] of total deaths) and the third-leading cause of death and disability combined (5·7% [5·1-6·2] of total DALYs) in 2019. From 1990 to 2019, the absolute number of incident strokes increased by 70·0% (67·0-73·0), prevalent strokes increased by 85·0% (83·0-88·0), deaths from stroke increased by 43·0% (31·0-55·0), and DALYs due to stroke increased by 32·0% (22·0-42·0). During the same period, age-standardised rates of stroke incidence decreased by 17·0% (15·0-18·0), mortality decreased by 36·0% (31·0-42·0), prevalence decreased by 6·0% (5·0-7·0), and DALYs decreased by 36·0% (31·0-42·0). However, among people younger than 70 years, prevalence rates increased by 22·0% (21·0-24·0) and incidence rates increased by 15·0% (12·0-18·0). In 2019, the age-standardised stroke-related mortality rate was 3·6 (3·5-3·8) times higher in the World Bank low-income group than in the World Bank high-income group, and the age-standardised stroke-related DALY rate was 3·7 (3·5-3·9) times higher in the low-income group than the high-income group. Ischaemic stroke constituted 62·4% of all incident strokes in 2019 (7·63 million [6·57-8·96]), while intracerebral haemorrhage constituted 27·9% (3·41 million [2·97-3·91]) and subarachnoid haemorrhage constituted 9·7% (1·18 million [1·01-1·39]). In 2019, the five leading risk factors for stroke were high systolic blood pressure (contributing to 79·6 million [67·7-90·8] DALYs or 55·5% [48·2-62·0] of total stroke DALYs), high body-mass index (34·9 million [22·3-48·6] DALYs or 24·3% [15·7-33·2]), high fasting plasma glucose (28·9 million [19·8-41·5] DALYs or 20·2% [13·8-29·1]), ambient particulate matter pollution (28·7 million [23·4-33·4] DALYs or 20·1% [16·6-23·0]), and smoking (25·3 million [22·6-28·2] DALYs or 17·6% [16·4-19·0]).

INTERPRETATION

The annual number of strokes and deaths due to stroke increased substantially from 1990 to 2019, despite substantial reductions in age-standardised rates, particularly among people older than 70 years. The highest age-standardised stroke-related mortality and DALY rates were in the World Bank low-income group. The fastest-growing risk factor for stroke between 1990 and 2019 was high body-mass index. Without urgent implementation of effective primary prevention strategies, the stroke burden will probably continue to grow across the world, particularly in low-income countries.

FUNDING

Bill & Melinda Gates Foundation.

Aphasia-Diagnostic Challenges and Trends: Speech-Language Pathologist's Perspective

Objectives

To explore current aphasia assessment practices and barriers among Pakistani speech language pathologists.

Methods

Descriptive study design with qualitative parameters was used. Participants were identified using purposive sampling over a period of eight months from 1st December 2018 to 31st July 2019. Sample comprised of ten speech-language pathologists with least five years' experience of working with aphasic clients from four major cities of Pakistan including Islamabad, Karachi, Lahore and Peshawar. Study included in depth interviews using a self-structured interview guide with probe questions. Data recorded was transcribed and thematic analyses were drawn manually.

Results

Thematic analysis revealed that most Speech language pathologists rely heavily on informal assessment techniques. With no aphasia assessment tool available in Urdu language, no consensus as to the optimal evaluation strategy or tool for aphasia assessment was noted. However, need for such tool was highlighted by all participants. Hence, non-availability of standardized and culturally appropriate assessment tool in "Urdu" language turned out to be the major barrier in adopting formal assessment for aphasic clients, while time consumed in formal testing remained second most reported issue.

Conclusion

There is a dire need of quick aphasia assessment tool in Urdu language with established psychometric properties and culturally appropriate norms.

Jalca Cantos L, Calderón Delgado EP, Yaguache Celi RM, Silva Saltos CA, Zamora A, Mastarreno M, Portalanza D. Injury patterns among road traffic accidents: a hospital-based study in Ecuador

Traffic accidents are serious public health problems, account for profound economic costs to individuals, families, and societies. The social impacts range from physiological to economic causes, which could be a serious negative effect, especially in undeveloped countries. To further elucidate this problem, the prevalence of injuries caused by traffic accidents in a Santa Ana Health Centre, Portoviejo, Ecuador, was studied. This registry-based retrospective study analyzed data on Santa Ana, from Enero 2016 to Diciembre 2019, and the medical records of patients who had been admitted were extracted and analyzed. Passengers cars, motorcycles, and bicycles involved in collisions were included, and the information collected was relating to sex, age, and type of injuries. In total, 75%±6.34 patients victims of road traffic injuries were males, and their mean age was 20 and 49 years. There was a cooperative agreement between total injury occurrence (%) and type of vehicle. Bus and car accidents had lower relation (R2 = 0.44, 078) (p = 0.063, 0.005) with total occurrence. The highest relation was found in motorbikes (R2 = 0.98 p = 2e-05), since it's the primary or most popular means of transportation in the city. The best of our knowledge is the first study to reporting data on road traffic injuries in the Province of Manabí, the third-largest province in extension in Ecuador. Additional studies with larger populations are thus necessary to construct a robust data system in undeveloped countries that can facilitate the flow of reliable information about road traffic injuries.

Rural Stroke Surveillance and Establishment of Acute Stroke Care Pathway Using Frontline Health Workers in Rural Northwest India: The Ludhiana Experience

BACKGROUND AND PURPOSE

The role of community health workers (CHWs) in stroke surveillance and in establishing the stroke care pathway has not been studied. The aim of the study was to evaluate the feasibility of using CHWs in the public health system to identify stroke patients for population-based stroke registration and to study the establishment of acute stroke care pathway in rural areas of Ludhiana, Punjab, Northwest India.

METHODS

Two rural blocks in Ludhiana district, comprising 164 villages and a population of 259,778, were selected. Phase-1 (feasibility study) was from August to November 2016 and phase-2 from December 2016 to November 2018. All first-ever stroke cases in adults (aged ≥18 years) were included. The accredited social health activists (ASHAs) were trained to identify stroke patients in the community, who were later evaluated by a neurologist. Stroke characteristics were recorded, and the outcome was assessed at 6 months using modified Rankin scale (0-2, good outcome).

FINDINGS

During phase-2, 359 first-ever stroke patients and 102 stroke mimics were identified. The age-standardized incidence rate was 218.5/100,000 and 197∙6/100,000 for each year. Half (52.4%) of the patients reached health-care facilities within 4.5 h, yet none of them received thrombolysis. Very few patients (1.9%) utilized free government 108 ambulance service to reach a health-care facility. Out of 359 stroke cases, the majority (306, 85.23%) were reported by ASHAs and 14.77% were reported by other sources. Brain imaging was available in 127 (35.4%) patients, and 100 (78.7%) had ischemic stroke. The most common risk factor was hypertension (320, 89%) and drug abuse (154, 42.9%). At 6 months, 168 (64%) patients had a good outcome.

CONCLUSION

ASHAs were able to identify stroke patients in the villages. Despite high numbers of patients reaching health-care facilities within a window period, the hospitals were unable to provide acute stroke treatment like thrombolysis. The health-care system needs to be strengthened to improve stroke care.

Effectiveness of physiotherapy interventions in brain plasticity, balance and functional ability in stroke survivors: A randomized controlled trial

BACKGROUND

Brain injuries such as strokes cause damage and death of the neuron cells. Physiotherapy interventions help to improve patient's performance and ability. However, this is only theorized but the impact of the physiotherapy intervention on brain plasticity is not known.

OBJECTIVE

The present study aimed to investigate the effect of physiotherapy interventions on brain neuroplasticity by evaluating the brain plasticity regeneration, balance and functional ability.

METHODS

A randomized controlled trial was conducted with 64 stroke patients from three hospitals in the Surakarta region, Indonesia. Control groups (n = 32) received conventional physiotherapy and intervention groups (n = 32) received neurorestoration protocol, which both lasted for seven days. Efficacy of the interventions were measured on brain-derived neurotropic factor serum analysis, Berg Balance Scale and Barthel Index, respectively.

RESULTS

Both groups showed improvements in all parameters but only balance and functional performance had a statistically significant outcome.

CONCLUSION

Neurorestoration protocol that combined several established physiotherapy interventions was effective in improving balance and functional ability of stroke patients in only a seven days period.

Gaps in secondary prevention among stroke survivors in rural Gadchiroli, India: a community-based cross-sectional study

Background: With epidemiological transition, stroke has emerged as a public health priority in rural India. However, population-level information on secondary prevention of stroke from rural areas of India and other low- and middle-income countries remains exceedingly rare. Methods: In a cross-sectional community-based survey, trained surveyors screened a well-defined population of 74,095 individuals living in 64 villages in Gadchiroli district of India for symptoms of stroke. A trained physician evaluated screen positive patients, diagnosed stroke, measured blood pressure and collected information on prior diagnosis of risk factors and current use of medications using a structured questionnaire. Results: A total of 265 stroke survivors were identified. Prior diagnosis of hypertension was made in 57.4%, diabetes in 9.8%, hyperlipidaemia in 0.4%, ischaemic heart disease in 1.5%. and atrial fibrillation in 1.1%. Blood pressure was uncontrolled (>140/90) in 46% of stroke survivors. Among men 71.2% used tobacco and 30% used alcohol, while among women 38.2% used tobacco and none used alcohol. Only 40.8% of stroke survivors were receiving antihypertensive medications, while 10.6% were on antiplatelet agents and 4.9% were on statins. In a multivariate analysis, age <50 years (OR 0.2, 95% CI 0.1-0.5), male sex (OR 0.2, 95% CI 0.2-0.8) and lower economic status (no assets vs four assets; OR 0.3, 95% CI 0.1-0.9) were associated with lower odds of receiving medications for secondary prevention of stroke. Conclusions: There were significant gaps in secondary prevention of stroke in rural Gadchiroli. Healthcare programmes for secondary prevention of stroke in rural areas will have to ensure that blood pressure is adequately controlled, alcohol and tobacco cessation is promoted and special attention is paid to those who are younger, men and economically weaker.

The Effectiveness of Botulinum Toxin Type A (BoNT-A) Treatment in Brazilian Patients with Chronic Post-Stroke Spasticity: Results from the Observational, Multicenter, Prospective BCause Study

Botulinum toxin type A (BoNT-A) is an effective treatment for post-stroke spasticity; however, some patients cannot access treatment until ≥1 year post-stroke. This Brazilian post-marketing study (NCT02390206) assessed the achievement of person-centered goals in patients with chronic post-stroke spasticity after a BoNT-A injection. Patients had a last documented stroke ≥1 year before study entry and post-stroke upper limb (UL) spasticity, with or without lower limb (LL) spasticity. Patients received BoNT-A injections at baseline (visit 1) and visit 2 (3–6 months). Primary endpoint was responder rate (achievement of primary goal from Goal Attainment Scaling (GAS)) at visit 2. Overall, 204 patients underwent GAS evaluation at visit 2, mean (SD) age was 56.4 (13.2) years and 90.7% had LL spasticity. Median (range) time between first stroke and onset of spasticity was 3.6 (0−349) months, onset of spasticity and first injection was 22.7 (0−350) months and waiting time for a rehabilitation appointment was 9.0 (1−96) months. At visit 2, 61.3% (95% CI: 54.4, 67.7) of patients were responders, which was similar for UL and LL primary goals (57.8% [95% CI: 49.9, 65.3] vs. 64.1% [95% CI: 48.4, 77.3]). This study provides evidence to support the effectiveness of BoNT-A treatment for chronic post-stroke spasticity.

Addressing Stroke Literacy in Nigeria Through Music: A Qualitative Study of Community Perspectives

BACKGROUND

The incidence of stroke in Nigeria is unknown, but stroke literacy, defined here as awareness of stroke warning symptoms and risk factors may be poor in high-risk communities. Although there is growing recognition of the use of music as a conduit to promote health literacy, African music is often overlooked as a source of health information. We sought to understand community-level perspectives on using African music to promote acute stroke literacy.

METHODS

A purposive sample of education, health and music professionals, high school and university students were recruited to participate in the qualitative study. Study participants completed a brainstorming exercise that elicited their perceptions of potential barriers and facilitators to the use of music to promote acute stroke literacy in Nigeria. Content analysis was used to identify key themes emerging from the brainstorming exercise.

RESULTS

A total of 44 individuals, comprising of 25 students with a mean age of 15.9 ± 1.6 years (52% females) and 19 professionals with a mean age of 39 ± 7.7 years (57.9% males) participated in the brainstorming exercise. Facilitators to the use of music to promote acute stroke literacy in Nigeria include the cultural relevance of music, the ubiquity of music, and government involvement. Key barriers include religious beliefs that discourage the use of "secular" music, cost-related barriers, and limited government support.

CONCLUSIONS

Findings from this study provide guidance aimed at improving acute stroke literacy in Nigeria, particularly the importance of government involvement in the development and implementation of stroke literacy interventions guided by African music. Future work should consider implementing interventions that leverage the cultural elements of African music and further assess the extent to which these identified facilitators and/or barriers may influence stroke literacy.

Awareness about stroke among high and low risk individuals in Khartoum, Sudan: a cross-sectional study

Introduction

stroke causes 10.17% of all deaths in Sudan. Levels of stroke awareness amongst patients in Sudan are unknown. The aim of this study is to assess the level of awareness of stroke risk factors, symptoms and immediate management amongst high and low risk patients.

Methods

using descriptive cross-sectional study, participants of high and low risk groups were recruited from the referral clinics of three tertiary hospitals in Khartoum. Data was collected through interviews using structured questionnaire. Knowledge score was devised to assess the awareness about stroke symptoms, risk factors, and management.

Results

of the 286 participants, 150 were females. The mean age was 44.66 years. About 79.4% reported that stroke is preventable. Hypertension was the most identified risk factor (71.6%) while genetics (0.2%) and alcohol (0.2%) were the least identified risk factors. Twenty-seven percent (27.6%) did not know any stroke risk factors, while 32.9% did not know any warning symptoms. Paralysis of one side of the body was the most identified warning symptom (30.7%). The mean awareness score was 21.9 ± 3.4 among the high risk group vs. 22.1 ± 3.6 among the low risk group with no statistically significant difference between the two groups (p = .717). The mean awareness score was statistically associated with the level of education (p < 0.001).

Conclusion

the awareness level was relatively low and not statistically different between high and low risk groups. We recommend the development of an effective educational program for the whole community.

A 'new normal' following COVID-19 and the economic crisis: Using systems thinking to identify challenges and opportunities in disability, telework, and rehabilitation

BACKGROUND

The novel coronavirus (COVID-19) that emerged in late 2019, and later become a global pandemic, has unleashed an almost unprecedented global public health and economic crisis.

OBJECTIVE

In this perspective, we examine the effects of COVID-19 and identify a likely 'new normal' in terms of challenges and opportunities within the fields of disability, telework, and rehabilitation.

METHODS

We use a systems thinking lens informed by recent empirical evidence and peer-reviewed qualitative accounts regarding the pandemic to identify emerging challenges, and pinpoint opportunities related to health and changing employment infrastructure of people with disabilities and rehabilitation professionals.

RESULTS

From our interpretation, the key leverage points or opportunities include: (1) developing disability-inclusive public health responses and emergency preparedness; (2) enabling employment and telework opportunities for people with disabilities; (3) addressing the new requirements in rehabilitation service provision, including participating as essential team members in the care of people with infectious diseases such as COVID-19; (4) embracing the added emphasis on, and capacity for, telehealth; and (5) developing greater resilience, distance learning, and employability among the rehabilitation workforce.

CONCLUSIONS

The COVID-19 pandemic has become increasingly challenging to the lives of people with disabilities and rehabilitation professionals; however, key challenges can be minimized and opportunities can be capitalized upon in order to 'build back better' after COVID-19.

Stroke rehabilitation in low-income and middle-income countries: a call to action

The WHO Rehabilitation 2030 agenda recognises the importance of rehabilitation in the value chain of quality health care. Developing and delivering cost-effective, equitable-access rehabilitation services to the right people at the right time is a challenge for health services globally. These challenges are amplified in low-income and middle-income countries (LMICs), in which the unmet need for rehabilitation and recovery treatments is high. In this Series paper, we outline what is happening more broadly as part of the WHO Rehabilitation 2030 agenda, then focus on the specific challenges to development and implementation of effective stroke rehabilitation services in LMICs. We use stroke rehabilitation clinical practice guidelines from both high-income countries and LMICs to highlight opportunities for rapid uptake of evidence-based practice. Finally, we call on educators and the stroke rehabilitation clinical, research, and not-for-profit communities to work in partnership for greater effect and to accelerate progress.

Figuring it out by yourself: Perceptions of home-based care of stroke survivors, family caregivers and community health workers in a low-resourced setting, South Africa

BACKGROUND

In less resourced settings, formal rehabilitation services for stroke survivors were often absent. Stroke survivors were referred to community health workers (CHWs) who were untrained in rehabilitation.

AIM

To describe the experience and perceived needs of stroke survivors, their caregivers and CHWs in a context with limited access to and support from formal rehabilitation services.

SETTING

The Breede Valley subdistrict, Western Cape, South Africa, a rural, less resourced setting.

METHODS

A descriptive exploratory qualitative study. Four focus group interviews were held with purposively selected stroke survivors and caregivers and four with CHWs. A thematic approach and the framework method were used to analyse the transcripts.

FINDINGS

A total of 41 CHWs, 21 caregivers and 26 stroke survivors participated. Four main themes and 11 sub-themes were identified. Because of the lack of knowledge, training and rehabilitation services, the main theme for all groups was having to 'figure things out' independently, with incontinence management being particularly challenging. Secondly was the need for emotional support for stroke survivors and caregivers. Thirdly, contextual factors such as architectural barriers and lack of assistive products negatively impacted care and function. Lastly, the organisation of health and rehabilitation services negatively impacted home-based services and professional support.

CONCLUSIONS

With appropriate training, the CHWs can be pivotal in the training and support of family caregivers and stroke survivors. Care pathways and the role and scope of both CHWs and therapists in home-based stroke rehabilitation should be defined and restructured, including the links with formal services.

Nonlinear relationship between serum total bilirubin levels and initial ischemic stroke in patients with non-valvular atrial fibrillation

Objective

This study aimed to examine the relationship between total bilirubin levels and initial ischemic stroke in patients with non-valvular atrial fibrillation.

Methods

This was a retrospective study. Atrial fibrillation was diagnosed by 24-hour Holter electrocardiography and serum total bilirubin levels were divided into quintiles. Ischemic stroke was diagnosed by symptoms, signs, and a medical image examination. The multivariate Cox proportional hazards model and survival analysis were used to estimate the association of total bilirubin with initial ischemic stroke.

Results

We studied 316 patients with non-valvular atrial fibrillation. During follow-up, there were 42 (13.29%) first ischemic strokes. After multivariate adjustment, for each 1 µmol/L increase in total bilirubin, the risk of first ischemic stroke increased by 4% (95% confidence interval [CI]: 1.01, 1.07). When using the first quintile as the reference, from the second to fifth quintiles, the risks of first ischemic stroke were 0.52 (95% CI: 0.17, 1.65), 0.23 (95% CI: 0.06, 0.87), 0.92 (95% CI: 0.32, 2.67), and 1.33 (95% CI: 1.09, 4.41), respectively. The optimal cut-off point of total bilirubin for the lowest risk of ischemic stroke was 17.0 µmol/L.

Conclusions

Total bilirubin levels are nonlinearly associated with initial ischemic stroke in patients with non-valvular atrial fibrillation.

Magnitude of risk factors and in-hospital mortality of stroke in Ethiopia: a systematic review and meta-analysis

Background

The morbidity and mortality of stroke is disproportionately high in developing countries owing to the poor health care system and poor neurologic interventions. Though a number of studies were conducted to estimate the in-hospital mortality rate of stroke in Ethiopia, the lack of a nationwide study that determines the overall magnitude of risk factors and in-hospital mortality rate of stroke is an important research gap. Meta-analysis is key to improve the accuracy of estimates through the use of more data sets. Thus, this study was aimed to determine the overall magnitude of risk factors and in-hospital mortality rate of stroke in Ethiopia.

Methods

This study was conducted following the PRISMA checklist. We searched from Google Scholar, PubMed, Science Direct, Web of Science, CINAHL, and Cochrane Library databases for studies. Each of the original studies was assessed using a tool for the risk of bias adapted for cross-sectional studies. Data were pooled and a random effect meta-analysis model was fitted to provide the overall magnitude of risk factors and in-hospital mortality rate of stroke. Also, the subgroup analyses were performed to examine how the in-hospital mortality rate varies across different groups of studies.

Results

In this study, the overall magnitude of hypertension, diabetes mellitus, and atrial fibrillation among stroke patients were 47% (95%CI: 40–54), 8% (95CI%:6–12), and 10% (95%CI: 5–19), respectively. The overall in-hospital mortality of stroke in Ethiopia was 18% (95%:14–22). The highest magnitude of in-hospital mortality of stroke was observed in SNNPR and the lowest was noted in Tigray region. In addition, the magnitude of the in-hospital mortality rate of stroke was 15.1% (95%CI: 11.3–19.4), and 19.6%(95%CI: 14.1–25.7), among studies published before and after 2016, respectively.

Conclusions

Our pooled result showed that nearly one-fifth of stroke patients have died during hospitalization. The most common risk factor of stroke among the included studies was hypertension followed by atrial fibrillation and diabetes mellitus. There is a need for a better understanding of the factors associated with high blood pressure, especially in countries with a high risk of stroke.

Influence of task-oriented circuit training on upper limb function among rural community-dwelling survivors of stroke

Background

Task-oriented circuit training using a Multi-Activities workstation emphasises goal-oriented tasks practiced in a circuit or series in order to learn a new skill. It can be used for upper limb rehabilitation among stroke patients in a community setting, but there is currently very little evidence available regarding its use in this patient group and setting. This study aimed to explore the influence of task-oriented circuit training using a Multi-Activities workstation on upper limb function among community-dwelling individuals with chronic stroke.

Methods

A pre-test–post-test study was conducted involving 17 community-dwelling individuals with chronic stroke who were attending a stroke rehabilitation centre. Six weeks of task-oriented circuit training was given using a Multi-Activities workstation aimed to improve strength, range of motion and dexterity. Streamlined Wolf Motor Function Test and Chedoke Arm and Hand Activity Inventory were used to measure outcomes. Wilcoxon signed-rank test was used for data analysis.

Results

A total of 12 sessions of task-oriented circuit training using Multi-Activities workstations did not result in any statistically significant differences in outcome measures.

Conclusions

Task-oriented circuit training using the Multi-Activities workstation did not improve upper limb function in community-dwelling individuals with chronic stroke.

Post-stroke Quality of Life Index: A quality of life tool for stroke survivors from Sri Lanka

Background

Burden of stroke is rising due to the demographic and epidemiological transitions in Sri Lanka. Assessment of success of stroke-management requires tools to assess the quality of life (QOL) of stroke survivors. Most of currently used QOL tools are developed in high-income countries and may not reflect characteristics relevant to resource-constrained countries. The aim was to develop and validate a new QOL tool for stroke survivors in Sri Lanka.

Methods

The COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist was referred. A conceptual framework was prepared. Item generation was done reviewing the existing QOL tools, inputs from experts and from stroke survivors. Non-statistical item reduction was done for the 36 generated items with modified-Delphi technique. Retained 21 items were included in the draft tool. A cross sectional study was done with 180 stroke survivors. Exploratory Factor Analysis was done and identified factors were subjected to varimax rotation. Further construct validity was tested with 6 a-priori hypothesis using already validated tools (SF-36, EQ-5D-3 L) and a formed construct. Internal consistency reliability was assessed with Cronbach alpha.

Results

Four factors identified with principal-component-analysis explained 72.02% of the total variance. All 21 items loaded with a level > 0.4. The developed tool was named as the Post-stroke QOL Index (PQOLI). Four domains were named as “physical and social function”, “environment”, “financial-independence” and “pain and emotional-wellbeing”. Four domain scores of PQOLI correlated as expected with the SF-36, EQ-5D Index and EQ-5D-VAS scores. Higher domain scores were obtained for ambulatory-group than the hospitalized-group. Higher scores for financial-independence domain were obtained for the group without financial-instability. Five a-priori hypothesis were completely proven to be true. Cronbach-alpha level ranged from 0.682 to 0.906 for the four domains.

Conclusions

There is first evidence for sufficient construct validity of the PQOLI as a valid QOL tool for measuring the QOL of stroke survivors with satisfactory internal consistency reliability.

Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review

Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required. Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries. Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018. Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded. Obtained data were synthesized thematically and descriptively analyzed. Results: One thousand nine hundred and ninety six studies were identified while 347 (65.22% high quality) RCTs were found to be eligible for the review. The most commonly assessed variables (and outcome measure utility) were activities of daily living [75.79% of the studies, with Barthel Index (37.02%)], motor function [66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min walk test (38.67%)]. Majority of the innovatively high technology interventions such as robot therapy (95.24%), virtual reality (94.44%), transcranial direct current stimulation (78.95%), transcranial magnetic stimulation (88.0%) and functional electrical stimulation (85.00%) were conducted in high income countries. Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke. Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life.

Differences in factors influencing the use of eRehabilitation after stroke; a cross-sectional comparison between Brazilian and Dutch healthcare professionals

BACKGROUND

To improve the use of eRehabilitation after stroke, the identification of barriers and facilitators influencing this use in different healthcare contexts around the world is needed. Therefore, this study aims to investigate differences and similarities in factors influencing the use of eRehabilitation after stroke among Brazilian Healthcare Professionals (BHP) and Dutch Healthcare Professionals (DHP).

METHOD

A cross-sectional survey study including 88 statements about factors related to the use of eRehabilitation (4-point Likert scale; 1-4; unimportant-important/disagree-agree). The survey was conducted among BHP and DHP (physical therapists, rehabilitating physicians and psychologists). Descriptive statistics were used to analyse differences and similarities in factors influencing the use of eRehabilitation.

RESULTS

ninety-nine (response rate 30%) BHP and 105 (response rate 37%) DHP participated. Differences were found in the top-10 most influencing statements between BHP and DHP BHP rated the following factors as most important: sufficient support from the organisation (e.g. the rehabilitation centre) concerning resources and time, and potential benefits of the use of eRehabilitation for the patient. DHP rated the feasibility of the use of eRehabilitation for the patient (e.g. a helpdesk and good instructions) as most important for effective uptake. Top-10 least important statements were mostly similar; both BHP and DHP rated problems caused by stroke (e.g. aphasia or cognitive problems) or problems with resources (e.g. hardware and software) as least important for the uptake of eRehabilitation.

CONCLUSION

The results indicate that the use of eRehabilitation after stroke by BHP and DHP is influenced by different factors. A tailored implementation strategy for both countries needs to be developed.

A nurse-led health coaching intervention for stroke survivors and their family caregivers in hospital to home transition care in Chongqing, China: a study protocol for a randomized controlled trial

BACKGROUND

Hospital to home transition care is a most stressful period for stroke survivors and their caregivers to learn self-management of stroke-related health conditions and to engage in rehabilitation. Health coaching has been identified as a strategy to enhance self-management of poststroke care at home. However, interventions in this field that are informed by a health coaching framework are scarce. This study will address a gap in research by testing the hypothesis that a nurse-led health coaching intervention can improve health outcomes for stroke survivors and their family caregivers in hospital to home transition care.

METHODS

This is a single-blind, two-arm parallel randomized controlled trial of a nurse-led health coaching program versus routine care situated in two tertiary hospitals in Chongqing, China. Stroke survivors and their primary family caregivers will be recruited together as "participant dyads", and the estimated sample size is 140 (70 in each group). The intervention includes a 12-week nurse-led health coaching program in hospital to home transition care commencing at discharge from the hospital. The primary outcome is changes in self-efficacy of stroke survivors at 12 weeks from the baseline. The secondary outcomes are changes in stroke survivors' and quality of life, functional ability, stroke-related knowledge, the number of adverse events, and unplanned hospital admissions, and caregivers' self-efficacy and caregiver-related burden at 12 weeks from the baseline. The outcomes will be measured at 12 weeks and 24 weeks from the baseline.

DISCUSSION

This study will examine the effect of nurse-led health coaching on hospital to home transition care for stroke survivors and their caregivers. It is anticipated that findings from this trial will provide research evidence to inform policy, and resource and practice development to improve hospital to home transition care for stroke survivors and their caregivers.

TRIAL REGISTRATION

The Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12619000321145. Registered on 1 March 2019.