Potential role of tele-rehabilitation to address barriers to implementation of physical therapy among West African stroke survivors: A cross-sectional survey

Analyzing the barriers and enablers to internet hospital implementation: a qualitative study of a tertiary hospital using TDF and COM-B framework

Background

Internet hospitals have become an important way to improve the accessibility of medical services and promote medical equity in China. However, there is still lack of research on the behavior of medical personnel during the process of using Internet medical services, and the elements of behavior that motivate doctors to actively use or resist the use of Internet hospitals are still not fully analyzed. The study applied the Theoretical Domains Framework to examine the factors affecting the engagement of medical personnel in Internet hospitals, with the aim of guiding the design of intervention to enhance Internet hospital participation.

Methods

This study utilized qualitative analysis. Semi-structured questionnaires based on the Theoretical Domains Framework (TDF) and Capability-Opportunity-Motivation-Behavior (COM-B) model was developed and administered to 40 doctors and nurses at a Grade A tertiary hospital in Guangdong Province. Data was coded and analyzed using qualitative methods including Nvivo software.

Results

The research displayed 19 barriers and 7 enablers for the implementation of Internet hospitals, all 14 TDF domains impacted participation with motivation cited most frequently. Despite challenges, medical personnel exhibited a generally optimistic stance towards utilization of the Internet hospital. Major barriers include the higher requirement of diagnostic ability, objective difficulties brought by online consultation to the decision-making process, limitation of time and other resources, not ideal technological and institutional environment, lack of self-efficacy and negative expectation of results in online consultation. Key enablers include patient needs and the positive impact of online care on the medical process and patient experience.

Discussion

This qualitative study identified a range of barriers and enablers to Internet hospital participation according to medical personnel, providing an conceptual framework to guide further research evaluating implementation strategies. Expanded research and targeted interventions design can help optimize participation in this evolving healthcare delivery model.

Enhancing stroke care in Ghana: A systematic review of stroke rehabilitation services

OBJECTIVE

In Ghana, the shifting demographics of stroke incidence towards young adults have prompted the expansion of stroke care and rehabilitation efforts. Nevertheless, the precise impact of stroke rehabilitation remains unclear. We conducted a systematic review to explore the landscape and effects of stroke rehabilitation in Ghana.

METHOD

We identified articles on stroke rehabilitation services in Ghana through searches of PubMed, Scopus, Embase, and Web of Science from inception until February 2024. The Critical Appraisal Skills Programme (CASP) Qualitative Checklist was employed to assess the risk of bias in the included studies, supplemented by qualitative synthesis.

RESULTS

Among the 213 articles screened, 8 were deemed suitable for review. These studies primarily focused on two groups: stroke survivors (n = 335) and healthcare professionals (HCPs) (n = 257). Many stroke survivors reported significant benefits from telerehabilitation, with increased participation in rehabilitation activities correlating with improved physical and cognitive outcomes. The findings also underscored a lack of knowledge about stroke rehabilitation among HCPs, alongside variations in the availability of protocols and guidelines for stroke management across different hospital levels.

CONCLUSIONS

The review reveals several challenges in stroke rehabilitation in Ghana, including disparities in HCPs' perceptions and utilization of rehabilitation services. The findings emphasize the need for comprehensive, patient-centered approaches, standardized training for HCPs, improved resource allocation, and the integration of telehealth to overcome barriers and enhance stroke rehabilitation in Ghana. These insights hold significance not only for Ghana but also for guiding strategies in similar contexts worldwide, aiming to improve stroke rehabilitation outcomes.

Effect of internet-based pulmonary rehabilitation on physical capacity and health-related life quality in patients with chronic obstructive pulmonary disease-a systematic review and meta-analysis

PURPOSE

Pulmonary rehabilitation (PR) is now recognized as the most effective treatments for individuals with chronic obstructive pulmonary disease (COPD), internet-based PR arises a promising method. The aim of this study was to conduct a systematic review and meta-analysis for assessing the effect of internet-based PR programs on physical capacity and health-related quality of life in patients with COPD.

MATERIALS AND METHODS

Randomized controlled trials were identified through systematically searches in PubMed, EMBASE, web of science, CENTRAL, Cochrane Library, and Google Scholar databases.

RESULTS

Twelve studies (1433 patients) were included. For physical capacity, there was no significant difference between groups was found according to the 6-min walk test (6MWT) (MD10.42, 95% CI -2.92 to 23.77, p = 0.13, I2 = 0%). For the health-related quality of life, no significant difference between groups was found regarding the St George's Respiratory Questionnaire (SGRQ) (MD -0.64, 95% CI -3.52 to 2.23, p = 0.66), COPD assessment test (CAT)(MD -0.34, 95% CI -1.62 to 0.94, p = 0.60), modified Medical Research Council scale (mMRC)(MD 0.17, 95% CI -0.06 to 0.39, p = 0.15) and Chronic Respiratory Questionnaire (CRQ)(MD 1.32 95% CI -5.88 to 8.53, p = 0.72).

CONCLUSIONS

This study has established the potential for delivery of PR via the internet in demonstrating non-inferiority of physical capacity and health-related quality of life (HRQoL) compared with conventional PR.IMPLICATIONS FOR REHABILITATIONLong-term rehabilitation training for patients with chronic obstructive pulmonary disease needs a more convenient and feasible way.In this study, internet-based rehabilitation showed similar effects as conventional rehabilitation on physical activity and health-related quality of life.Internet-based rehabilitation strategies would be helpful for this population.All internet-based rehabilitation strategies should be simple and sustainable.

Views of Service Users, Their Family or Carers, and Health Care Professionals on Telerehabilitation for People With Neurological Conditions in Ghana: Qualitative Study

BACKGROUND

Up to 50% of people in low- and middle-income countries do not receive the rehabilitation they require. Telerehabilitation has the potential to improve access to neurorehabilitation services especially in low- and middle-income countries. Although there are reports of the barriers and facilitators to telerehabilitation in such settings, almost all are anecdotal. Furthermore, family or carers have a significant influence on the adoption and success of telerehabilitation, but their views have not been reported.

OBJECTIVE

This study aimed to investigate the views of service users, their family or carers, and health care professionals (HCPs) on telerehabilitation for people with neurological conditions in Ghana.

METHODS

Two focus groups were held at Komfo Anokye Hospital in Kumasi, Ghana: one in person for service users (n=11) and their family or carers (n=9), conducted in the Ghanaian language of Twi, and one hybrid for HCPs (n=18) conducted in English. The mean (SD) age of the service users was 59.8 (8.6) years; 5 users had a stroke and 6 had Parkinson disease. The HCP group consisted of 7 speech and language therapists, 3 physiotherapists, 3 occupational therapists, 3 medical staff, 1 nurse, and 1 industry representative. Focus groups were semi-structured and explored previous experiences of telerehabilitation, perceived benefits and challenges, and solutions to overcome these challenges. Focus groups were audio transcribed, and the service user transcript was translated into English. The resulting transcripts were analyzed using thematic analysis.

RESULTS

Overall, participants were positive about the role of telerehabilitation but recommended hybrid delivery, with in-person rehabilitation in the early stages and telerehabilitation in the later stages. In relation to telerehabilitation in Ghana, there were 3 main themes: benefits, challenges or barriers, and implementation. Benefits included the convenience and lower cost for service users, the higher dose of therapy possible, and increased access for people in remote areas. However, challenges included lack of a stable internet connection, cost of phones and data packages, and low levels of literacy. Implementation issues included cultural relevance, information governance, and the platform used to deliver telerehabilitation, with most participants being familiar with WhatsApp.

CONCLUSIONS

Telerehabilitation has the potential to be a useful method of delivering rehabilitation to people with neurological conditions in Ghana, especially in a hybrid rehabilitation model with telerehabilitation augmenting in-person sessions. However, many people were unaware of telerehabilitation, and challenges such as a reliable internet connection, cultural relevance, and costs need to be addressed. Clinical trials of low-cost telerehabilitation interventions contextualized to the specific user group are required.

Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission

Stroke is the second leading cause of death worldwide. The burden of disability after a stroke is also large, and is increasing at a faster pace in low-income and middle-income countries than in high-income countries. Alarmingly, the incidence of stroke is increasing in young and middle-aged people (ie, age <55 years) globally. Should these trends continue, Sustainable Development Goal 3.4 (reducing the burden of stroke as part of the general target to reduce the burden of non-communicable diseases by a third by 2030) will not be met.

In this Commission, we forecast the burden of stroke from 2020 to 2050. We project that stroke mortality will increase by 50%—from 6·6 million (95% uncertainty interval [UI] 6·0 million–7·1 million) in 2020, to 9·7 million (8·0 million–11·6 million) in 2050—with disability-adjusted life-years (DALYs) growing over the same period from 144·8 million (133·9 million–156·9 million) in 2020, to 189·3 million (161·8 million–224·9 million) in 2050. These projections prompted us to do a situational analysis across the four pillars of the stroke quadrangle: surveillance, prevention, acute care, and rehabilitation. We have also identified the barriers to, and facilitators for, the achievement of these four pillars. Disability-adjusted life-years (DALYs) The sum of the years of life lost as a result of premature mortality from a disease and the years lived with a disability associated with prevalent cases of the disease in a population. One DALY represents the loss of the equivalent of one year of full health

On the basis of our assessment, we have identified and prioritised several recommendations. For each of the four pillars (surveillance, prevention, acute care, and rehabilitation), we propose pragmatic solutions for the implementation of evidence-based interventions to reduce the global burden of stroke. The estimated direct (ie, treatment and rehabilitation) and indirect (considering productivity loss) costs of stroke globally are in excess of US$891 billion annually. The pragmatic solutions we put forwards for urgent implementation should help to mitigate these losses, reduce the global burden of stroke, and contribute to achievement of Sustainable Development Goal 3.4, the WHO Intersectoral Global Action Plan on epilepsy and other neurological disorders (2022–2031), and the WHO Global Action Plan for prevention and control of non-communicable diseases.

Reduction of the global burden of stroke, particularly in low-income and middle-income countries, by implementing primary and secondary stroke prevention strategies and evidence-based acute care and rehabilitation services is urgently required. Measures to facilitate this goal include: the establishment of a framework to monitor and assess the burden of stroke (and its risk factors) and stroke services at a national level; the implementation of integrated population-level and individual-level prevention strategies for people at any increased risk of cerebrovascular disease, with emphasis on early detection and control of hypertension; planning and delivery of acute stroke care services, including the establishment of stroke units with access to reperfusion therapies for ischaemic stroke and workforce training and capacity building (and monitoring of quality indicators for these services nationally, regionally, and globally); the promotion of interdisciplinary stroke care services, training for caregivers, and capacity building for community health workers and other health-care providers working in stroke rehabilitation; and the creation of a stroke advocacy and implementation ecosystem that includes all relevant communities, organisations, and stakeholders.

The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.

Nurse-led telerehabilitation intervention to improve stroke efficacy: Protocol for a pilot randomized feasibility trial

BACKGROUND

The prevalence of stroke continues to rise in low-middle income countries. The continual rise in stroke cases and increasing prevalence on post-acute needs represent a crucial call for increased accessibility and utilization of rehabilitation services.

AIM

The primary objective of the study is to test the feasibility of a nurse-led telerehabilitation intervention in improving self-efficacy among stroke survivors. The findings of the trial are intended for use in a future larger study.

METHODS

Participants would be recruited at the University of Ghana Hospital and randomized into an intervention group and a control group. Participants aged ≥ 18 years, diagnosed of stroke at most 12months prior the recruitment and requiring moderate level of assistance would be considered for eligibility. Participants in the intervention group will receive individualized and comprehensive nurse-led rehabilitation therapies in physical, emotional, cognitive and nursing education domains for 6 months, in addition to treatment as usual (TAU). The control group will only receive treatment as usual. Follow-up evaluations will occur immediately, 30 days and 90 days after the intervention.

DISCUSSION

Providing stroke rehabilitation services in low-resource settings presents a significant challenge due to limited infrastructure and a lack of trained healthcare professionals. The current study has the potential of contributing to the growing body of evidence on the impact of telerehabilitation services in mitigating these challenges in low-resource settings.

TRIAL REGISTRATION

PACTR202210685104862, Pan African Clinical Trial Registry.

Stroke Rehabilitation in Low- and Middle-Income Countries: Challenges and Opportunities

ABSTRACT

Stroke remains the second leading cause of global disability with 87% of stroke-related disability occurring in low- and middle-income countries. In low- and middle-income countries, access to acute stroke interventions is often limited, making effective poststroke rehabilitation potentially the best available intervention to promote poststroke recovery. Here, we build on our experience as an illustrative example of barriers individuals with stroke face in accessing rehabilitation services and review the literature to summarize challenges to providing effective rehabilitation in low- and middle-income countries. First, we focus on barriers individuals with stroke face in accessing rehabilitation in low- and middle-income countries, including health system barriers, such as lack of national guidelines, low prioritization of rehabilitation services, and inadequate numbers of skilled rehabilitation specialists, as well as patient factors, including limited health literacy, financial constraints, and transportation limitations. Next, we highlight consequences of this lack of rehabilitation access, including higher mortality, poorer functional outcomes, financial burden, caregiver stress, and loss of gross domestic product at a national level. Finally, we review possible strategies that could improve access and quality of rehabilitation services in low- and middle-income countries, including creation of inpatient stroke units, increased training opportunities for rehabilitation specialists, task shifting to available healthcare workers or caregivers, telerehabilitation, and community-based rehabilitation services.

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.

The Effectiveness of Telerehabilitation on Balance and Functional Mobility in Patients with Stroke: A Systematic Review and Meta-Analysis

Objective

The aim of this systematic review and meta-analysis was to investigate the effectiveness of telerehabilitation on improving balance and functional mobility in stroke survivors.

Methods

Comprehensive searching was conducted from inception to May 2022. The inclusion criteria were studies evaluating the effectiveness of telerehabilitation in stroke survivors. Data regarding participants, intervention, outcome measures, and main results were extracted. PEDro scale and the Grading of Recommendations Assessment Development and Evaluation (GRADE) were used to assess the methodological quality and quality of evidence, respectively.

Data Analysis

A total of fourteen articles) 594 patients) were included. A meta-analysis using a random-effect model was performed on thirteen studies )530 patients). Standardized mean difference (SMD) with 95% confidence interval (CI) was calculated for balance and functional mobility. Results: PEDro scale revealed ten good-quality studies, three fair-quality studies, and one poor-quality study. According to the available evidence, telerehabilitation has a small effect size in improving both balance (SMD 0.33 [95% CI 0.03 to 0.63]; P =0.03; low quality of evidence) and functional mobility (SMD 0.27 [95% CI 0.02 to 0.52]; P =0.03; low quality of evidence).

Conclusion

Telerehabilitation may improve balance and functional mobility in stroke survivors. However, it is evident that more high-quality research is required due to the existence of low to very low-quality evidence with limited confidence in the effect estimate.

Registration

PROSPERO registration number (CRD42022306410).

“I’m Just Overwhelmed”: Investigating Physical Therapy Accessibility and Technology Interventions for People with Disabilities and/or Chronic Conditions

Many individuals with disabilities and/or chronic conditions (da/cc) experience symptoms that may require intermittent or on-going medical care. However, healthcare is an often-overlooked domain for accessibility work, where access needs associated with temporary and long-term disability must be addressed to increase the utility of physical and digital interactions with healthcare workers and spaces. Our work focuses on a specific domain of healthcare often used by individuals with da/cc: physical therapy (PT). Through a twelve-person interview study, we examined how people’s access to PT for their da/cc  is hampered by social (e.g., physically visiting a PT clinic) and physiological (e.g., chronic pain) barriers, and how technology could improve PT access. In-person PT is often inaccessible to our participants due to lack of transportation and insufficient insurance coverage. As such, many of our participants relied on at-home PT to manage their da/cc  symptoms and work towards PT goals. Participants felt that PT barriers, such as having particularly bad symptoms or feeling short on time, could be addressed with well-designed technology that flexibly adapts to the person’s dynamically changing needs while supporting their PT goals. We introduce core design principles (adaptability, movement tracking, community building) and tensions (insurance) to consider when developing technology to support PT access. Rethinking da/cc  access to PT from a lens that includes social and physiological barriers presents opportunities to integrate accessibility and adaptability into PT technology.

Physical Activity Level and Perspectives of Participants Transitioning from Onsite to Virtual Cardiac Rehabilitation during the Early COVID-19 Pandemic: A Mixed-Method Study

This mixed-method study aimed to compare physical activity (PA) patterns of a cross-over cardiac rehabilitation (CR) cohort with a center-based CR cohort and to explore barriers and facilitators of participants transitioning and engaging in virtual CR. It included the retrospective self-reported PA of a cross-over CR cohort (n = 75) and a matched center-based CR cohort (n = 75). Some of the participants included in the cross-over cohort (n = 12) attended semi-structured focus group sessions and results were interpreted in the context of the PRECEDE-PROCEED model. Differences between groups were not observed (p > 0.05). The center-based CR cohort increased exercise frequency (p = 0.002), duration (p = 0.007), and MET/minutes (p = 0.007) over time. The cross-over cohort increased exercise duration (p = 0.04) with no significant change in any other parameters. Analysis from focus groups revealed six overarching themes classified under predisposing factors (knowledge), enabling factors (external support, COVID-19 restrictions, mental health, personal reasons/preferences), and reinforcing factors (recommendations). These findings suggest an improvement of the PA levels of center-based CR cohort participants pre-pandemic and mitigated improvement in those who transitioned to a virtual CR early in the pandemic. Improving patients’ exercise-related knowledge, provider endorsements, and the implementation of group videoconferencing sessions could help overcome barriers to participation in virtual CR.

Telerehabilitation for individuals with spinal cord injury in low-and middle-income countries: a systematic review of the literature

STUDY DESIGN

Systematic review.

OBJECTIVE

To systematically review the evidence for the effectiveness of telerehabilitation as an intervention for people with spinal cord injury (SCI) in low-and middle-income countries (LMICs).

SETTING

Not applicable.

METHODS

MEDLINE (Ovid), Embase (Ovid), Pubmed and Global Health databases were used to identify studies published between 1946-2020 meeting the following criteria: (1) patients with SCI diagnosis; (2) in LMIC; (3) an outcome measuring clinical functional ability, quality of life or all-cause mortality reduction. The risk of bias in studies was graded using revised Cochrane risk-of-bias tool in randomised trials (RoB 2) and risk-of-bias tool in non-randomised trials (ROBINS-I). Evidence levels were graded with Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

RESULTS

In total, 107 articles were identified from the initial search. After screening, five studies were included. Some significant improvements to quality of life and pressure ulcer management were observed, alongside some improvement in functional ability with suggested improvement to depression scores. Telerehabilitation alleviated participants' sense of social isolation, improved satisfaction scores and assisted them to remember techniques for SCI management. Telerehabilitation was valued by health professionals. There was no reduction in all-cause mortality.

CONCLUSION

There is insufficient evidence to recommend telerehabilitation as an intervention to treat and manage SCI in LMICs, although there is an indication of potential patient benefit. Further research is required to better understand the causal mechanisms underpinning the use of telerehabilitation and establish its efficacy, in the context of resource-limited settings.

Telerehabilitation for balance rehabilitation in the subacute stage of stroke: A pilot controlled trial

BACKGROUND

Telerehabilitation has been proposed as an effective strategy to deliver post-stroke specific exercise.

OBJECTIVE

To assess the effectiveness and feasibility of core stability exercises guided by a telerehabilitation App after hospital discharge.

METHODS

Extension of a prospective controlled trial. Subacute stage stroke survivors were included at the time of hospital discharge where they had participated in a previous 5-week randomized controlled trial comparing conventional physiotherapy versus core stability exercises. After discharge, patients from the experimental group were offered access to telerehabilitation to perform core stability exercises at home (AppG), while those from the control group were subject to usual care (CG). The Spanish-version of the Trunk Impairment Scale 2.0 (S-TIS 2.0), Function in Sitting Test (S-FIST), Berg Balance Scale (BBS), Spanish-version of Postural Assessment for Stroke Patients (S-PASS), the number of falls, Brunel Balance Assessment (BBA) and Gait were assessed before and after 3 months intervention.

RESULTS

A total of 49 subjects were recruited. AppG showed greater improvement in balance in both sitting and standing position and gait compared with CG, although no statistically significant differences were obtained.

CONCLUSION

Core stability exercises Telerehabilitation as a home-based guide appears to improve balance in post-stroke stage. Future studies are necessary to confirm the effects as well as identifying strategies to increase telerehabilitation adherence.

Telerehabilitation for lower extremity recovery poststroke: a systematic review and meta-analysis protocol

INTRODUCTION

Approximately 30% of individuals with stroke report unmet lower extremity recovery needs after formal hospital-based rehabilitation programmes have ended. Telerehabilitation can mitigate issues surrounding accessibility of rehabilitation services by providing ongoing support to promote recovery, however, no review exists that is specific to telerehabilitation for lower extremity recovery. This paper describes the protocol of a systematic review and meta-analysis that aims to describe and evaluate the effectiveness of lower extremity-focused telerehabilitation interventions on clinical outcomes poststroke.

METHODS AND ANALYSIS

A systematic review of relevant electronic databases (MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, Google Scholar, PEDro, PubMed and Cochrane Library) between inception and February 2022 will be undertaken to identify eligible interventional studies published in English that compared telerehabilitation focusing on lower extremity recovery to another intervention or usual care for individuals living in the community with stroke. Clinical outcomes examined will include those related to physical function and impairment, activities and participation that are typically assessed in clinical practice and research. Two reviewers will independently screen results, identify studies to be included for review, extract data and assess risk of bias. Meta-analyses will be performed if sufficient data exist. Sensitivity analyses will be performed by removing studies with low methodological quality, and subgroup analyses will be performed if data allow by stratifying papers based on salient demographic or stroke factors and comparing results. The reporting of the review will follow the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The quality of evidence regarding various outcomes for telerehabilitation for lower extremity recovery poststroke will be assessed according to the Grading of Recommendation, Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

No ethical approval or informed consent is needed for this systematic review. The findings of this review will be disseminated via peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42021246886.

Neurocognitive outcomes of tuberculous meningitis in a primarily HIV-positive Ugandan cohort

Background: The toll of tuberculous meningitis (TBM) in both mortality and disability is considerable, but advancements in rehabilitation have the potential to improve the functional abilities and the quality of survivors' lives. However, the typical phenotype of neurocognitive impairment in TBM survivors remains unstudied in HIV-predominant populations in sub-Saharan Africa. Methods: We tested 36 survivors of TBM in Uganda with a comprehensive battery of neurocognitive assessments at 8 and 24 weeks after diagnosis, and compared results to a representative cohort of HIV-uninfected Ugandans. Results: While participants had a broad range of impairments at eight weeks, there was marked improvement by 24 weeks, when a phenotype of impairment including deficits in motor functioning, verbal learning and memory, processing speed, and executive function emerged. These deficits were present despite good clinician-rated functional status. The majority (23/27, 85%) had evidence of moderate to severe depression at week 8, and at week 24 (18/24, 75%). Conclusion: These findings highlight the need for more comprehensive neurocognitive assessment in the survivors of TBM, and further investment in and study of rehabilitation, including management of depression, to improve long-term outcomes in this population.

Factors associated with the longer-term unmet supportive care needs of stroke survivors in Ethiopia: a multicentre cross-sectional study

OBJECTIVES

To assess the magnitude of the longer-term unmet supportive care needs and associated factors among adult stroke survivors.

DESIGN

Institutional-based multicentre cross-sectional study.

SETTING

Between 1 March 2020 and 31 May 2020, in Addis Ababa, Ethiopia.

PARTICIPANTS

Adult stroke survivors (aged ≥18 years, n=422), diagnosed with a stroke at least 6 months before the study period and who started regular follow-up at the neurology outpatient clinics in Addis Ababa, Ethiopia.

MAIN OUTCOME MEASURES

Self-reported longer-term supportive care needs.

RESULTS

Two hundred and twenty-six (53.6%) stroke survivors had longer-term unmet supportive care needs, and 196 (46.4%) survivors had no longer-term unmet supportive care needs. Information need about stroke was reported by 416 (98.6%), and how to travel on public transportation was reported by 340 (80.6%) survivors. These were the most frequently reported unmet needs. Stroke survivors' longer-term unmet supportive care needs were significantly associated with being hypertensive with (adjusted OR (AOR) 4.59; 95% CI 2.61 to 8.07), having heart disease with (AOR 1.94; 95% CI 1.19 to 3.82), moderate and above level of disability according to the modified Rankin Scale score with (AOR 26.4; 95% CI 8.61 to 80.92) and unable to use the physiotherapy service with (AOR 2.85; 95% CI of 1.63 to 4.99).

CONCLUSIONS

There are significant longer-term unmet supportive care needs among adult stroke survivors. The factors associated with longer-term unmet supportive care needs were; having comorbidities, moderate and above level of disability according to the modified Rankin Scale score and unable to use the physiotherapy service. The development of appropriate services to address the longer-term unmet supportive care needs of stroke survivors is warranted.

Telehealth for rehabilitation and recovery after stroke: State of the evidence and future directions

AIMS

The aim of this rapid review and opinion paper is to present the state of the current evidence and present future directions for telehealth research and clinical service delivery for stroke rehabilitation.

METHODS

We conducted a rapid review of published trials in the field. We searched Medline using key terms related to stroke rehabilitation and telehealth or virtual care. We also searched clinical trial registers to identify key ongoing trials.

RESULTS

The evidence for telehealth to deliver stroke rehabilitation interventions is not strong and is predominantly based on small trials prone to Type 2 error. To move the field forward, we need to progress to trials of implementation that include measures of adoption and reach, as well as effectiveness. We also need to understand which outcome measures can be reliably measured remotely, and/or develop new ones. We present tools to assist with the deployment of telehealth for rehabilitation after stroke.

CONCLUSION

The current, and likely long-term, pandemic means that we cannot wait for stronger evidence before implementing telehealth. As a research and clinical community, we owe it to people living with stroke internationally to investigate the best possible telehealth solutions for providing the highest quality rehabilitation.

Cognitive telerehabilitation in neurological patients: systematic review and meta-analysis

Telerehabilitation (TR) seems to be an encouraging solution for the delivery of cognitive treatments in patients with neurological disorders. This study was aimed to analyze and synthesize the evidence on the efficacy of cognitive TR interventions in patients with neurological diseases, compared with conventional face-to-face rehabilitation. From a total of 4485 records, 9 studies met the inclusion criteria for qualitative analysis. At the end of the process, 7 studies remained for quantitative analysis. By comparing TR with face-to-face treatments for cognitive impairments, we assessed improvements in global cognitive domain (Mini Mental State Exam) (MD = −0.86; 95% CI −2.43, 0.72, I² = 0%), in learning and memory domains (SMD = 0.26, 95% CI −0.22, 0.74, I² = 24%), in verbal fluency (SMD = 0.08, 95% CI −0.47, 0.62, I² = 0%), and in executive functions (i.e., problem-solving, central processing speed and working memory) (SMD = 0.38, 95% CI 0.06, 0.71, I² = 0%). In all the included studies, improvement in the performance of the TR groups was comparable to that achieved through face-to-face intervention. Significant differences between those two modalities of providing treatments were observed for working memory and total executive function comparison, in favor of TR. The results of this study can sustain the efficacy of TR and its application for the treatment of neurological patients, especially when treated for executive function impairments.

An ecological approach to understanding stroke experience and access to rehabilitation services in Ghana: A cross-sectional study

Despite a growing burden of stroke in low-middle-income countries, research on patient's experiences and access to rehabilitation services remains limited. This study explores the experiences of stroke patients in relation to access and use of stroke rehabilitation services, coping strategies and strategies to improve care in Ghana. A cross-sectional study was conducted. A total of 136 adult stroke patients hospitalised and subsequently discharged in three major referral hospitals in Ghana participated in the study. A paper-based questionnaire was used to collect data. Data were inputted into STATA version 12, cleaned and analysed using descriptive statistics and Chi-Square tests. Findings showed that stroke patients experience stroke differently. Early detection (awareness) of stroke symptoms at onset was low (29.4%). Hypertension was the major (58.1%) predisposing risk factor for stroke, followed by diabetes (14.7%). Multiple barriers impede access to outpatient rehabilitation services: high cost of medications (43.4%), transportation constraints (10.3%), long waiting time (6.6%), forgetfulness about appointment (4.4%), limited education on rehabilitation (20.6%), lack of community support (12.5%) and ineffective communication with healthcare providers (5.2%). Recommended strategies to improve access to rehabilitation care included public education on stroke and its associated risk, reduction in the cost of drugs and increased stroke rehabilitation funding by the NHIS, especially for physiotherapy consultation and training support to caregivers on patient care. Given the difference in stroke experience and barriers in accessing rehabilitation care, multi-level health policy and service delivery reforms are needed to improve access to rehabilitation care, including national public awareness campaigns on early signs of stroke and subsidised cost of stroke rehabilitation.

Tele-Rehabilitation to Combat Rehabilitation Service Disruption During COVID-19 in Hong Kong: Observational Study

Background

A tele-rehabilitation platform was developed to improve access to ambulatory rehabilitation services in Hong Kong. The development was completed in October 2019 and rolled out for use to occupational therapists, physiotherapists, and speech therapists. During the COVID-19 pandemic, rehabilitation services were severely interrupted. Tele-rehabilitation was used extensively to meet the demand for rehabilitation service delivery.

Objective

The aims of this study were to (1) describe the design and development process of a tele-rehabilitation service, and (2) study how the tele-rehabilitation platform was used to overcome the disruption of rehabilitation service during the COVID-19 pandemic.

Methods

Tele-rehabilitation was developed utilizing 4 core determinants of Unified Theory of Acceptance and Use of Technology as guiding principles. A generic prescription platform, called the activity-based prescription system, and a mobile app, called the Rehabilitation App, were built. Five outcomes were used to examine the utilization of tele-rehabilitation both before and during the pandemic: throughput, patient demographic, patient conditions, workforce, and satisfaction from patients and staff.

Results

There was a tremendous increase in the use of tele-rehabilitation during pandemic. The total number of patients (up until July 2020) was 9101, and the main age range was between 51 to 70 years old. Tele-rehabilitation was used for a much wider scope of patient conditions than originally planned. More than 1112 therapists, which constituted 50.6% of the total workforce (1112/2196), prescribed tele-rehabilitation to their patients. Moreover, there was a high satisfaction rate from patients, with a mean rating of 4.2 out of 5, and a high adherence rate to prescribed rehabilitation activities (107840/131995, 81.7%).

Conclusions

The findings of our study suggested that tele-rehabilitation in the form of a generic prescription platform and mobile app can be an effective means to provide rehabilitation to patient. During the COVID-19 pandemic, tele-rehabilitation has been used extensively and effectively to mitigate service disruption. Our findings also provide support that there is a high level of satisfaction with tele-rehabilitation; however, a longer duration study is required to demonstrate the sustained use of tele-rehabilitation, especially after the pandemic.

Neurocognitive outcomes of HIV-associated tuberculous meningitis

Background: The toll of tuberculous meningitis (TBM) in both mortality and disability is considerable, but advancements in rehabilitation have the potential to improve the functional abilities and the quality of survivors' lives. However, the typical phenotype of neurocognitive impairment in TBM survivors remains unstudied in HIV-predominant populations in sub-Saharan Africa. Methods: We tested 36 survivors of TBM in Uganda with a comprehensive battery of neurocognitive assessments at 8 and 24 weeks after diagnosis, and compared results to a representative cohort of HIV-uninfected Ugandans. Results: While participants had a broad range of impairments at eight weeks, there was marked improvement by 24 weeks, when a phenotype of impairment including deficits in motor functioning, verbal learning and memory, processing speed, and executive function emerged. These deficits were present despite good clinician-rated functional status. The majority (23/27, 85%) had evidence of moderate to severe depression at week 8, and at week 24 (18/24, 75%). Conclusion: These findings highlight the need for more comprehensive neurocognitive assessment in the survivors of TBM, and further investment in and study of rehabilitation, including management of depression, to improve long-term outcomes in this population.

Descriptive Review of Online Information Resources for People With Stroke: Protocol for a Scoping Review

Background

People with stroke and their caregivers experience numerous information needs; internet-based resources may offer cost-effective ways to improve access to information about this condition and its management, including the availability of resources and support. The quality of online health information is, therefore, an important consideration for both developers and consumers of these online resources.

Objective

This study aims to map and evaluate the content, readability, understandability, design, and quality characteristics of freely available online information resources (ie, websites) that empower people with stroke and their caregivers with information and self-help strategies poststroke.

Methods

This descriptive review will follow the five systematic and rigorous methodological steps that are recommended for scoping reviews, which include the following: (1) identifying the research question, (2) identifying relevant studies, (3) selecting the studies, (4) charting the data, and (5) collating, summarizing, and reporting the results. Data will then be synthesized and analyzed thematically.

Results

As of February 2021, the scoping review is in the data extraction stage. Data will be synthesized, and the first results are expected to be submitted for publication in an open-access peer-reviewed journal in August 2021. In addition, we will develop an accessible summary of the results for stakeholder meetings. Ethical approval is not required for this review, as it will only include publicly available information.

Conclusions

This study is novel and will evaluate the typology, content, and design-related criteria, including accessibility, aesthetics, navigability, interactivity, privacy, and data protection, of online information resources for stroke. The review will be limited to online resources published in English.

International Registered Report Identifier (IRRID)

DERR1-10.2196/23174

Quantitative and qualitative analyses of herbal medication use among Ghanaian stroke survivors

BACKGROUND

Herbal medicines are not regulated by regulatory authorities and are often not of proven safety and efficacy. Anecdotal reports suggest widespread use of traditional herbal medicine (THM) for treatment of stroke in Africa, but verifiable data are limited in published literature.

OBJECTIVE

To assess the frequency and reasons for THM use among Ghanaian stroke survivors.

METHODS

We conducted a cross-sectional survey of 106 consecutive stroke survivors presenting for care at a tertiary medical center in Kumasi, Ghana between June and October 2020. Information on demographic, clinical, vascular risk factors and use of THM were collected in a non-judgmental manner and analyzed.

RESULTS

Among the cohort, 46 (43.4%) reported use of any THM for their stroke management. There was a trend towards fewer women who reported use of THM 34.8% vs 53.3%, p = 0.06. Of those reporting use of THM, 78% had blood pressure > 140/90 mmHg vs. 56% among those not exposed to THM (p = 0.02). Top reasons proffered for use of THM were: expecting them to aid faster recovery from stroke (n = 30), expecting them to cure stroke (n = 18), and expecting them to be of superior effectiveness compared to approved conventional medications of proven efficacy/safety (n = 1).

CONCLUSION

Almost half the individuals in this contemporary sample of Ghanaian stroke survivors reported use of THM with expectations for improved outcomes. More counseling is required to inform patients about potential safety issues with THM use, and more research is needed to explore risk/benefit of promising THMs to improve stroke outcomes.

COVID-19 and Teleneurology in Sub-Saharan Africa: Leveraging the Current Exigency

Africa has over 1.3 billion inhabitants, with over 60% of this population residing in rural areas that have poor access to medical experts. Despite having a ridiculously huge, underserved population, very few African countries currently have any form of sustained and organized telemedicine practice, and even fewer have dedicated tele-neurology services. The ongoing COVID-19 pandemic has proved to be one of the most significant disruptors of vital sectors of human endeavor in modern times. In the healthcare sector, there is an increasing advocacy to deliver non-urgent care via telemedicine. This paper examined the current state of tele-neurology practice and infrastructural preparedness in sub-Saharan Africa. Currently, there is over 70% mobile phone penetration in most of the countries and virtually all of them have mobile internet services of different technologies and generations. Although the needed infrastructure is increasingly available, it should be improved upon. We have proposed the access, costs, ethics, and support (ACES) model as a bespoke, holistic strategy for the successful implementation and advancement of tele-neurology in sub-Saharan Africa.

Effect of Internet-Based Rehabilitation Programs on Improvement of Pain and Physical Function in Patients with Knee Osteoarthritis: Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

Osteoarthritis (OA) is a chronic, debilitating, and degenerative joint disease. However, it is difficult for patients with knee OA to access conventional rehabilitation when discharging from the hospital. Internet-based rehabilitation is one of the promising telemedicine strategies to provide a means combining monitoring, guidance, and treatment for patients with knee OA.

Objective

The aim of this study was to conduct a systematic review and meta-analysis for assessing the effect of internet-based rehabilitation programs on pain and physical function in patients with knee OA.

Methods

Keywords related to knee OA and internet-based rehabilitation were systematically searched in the Web of Science, MEDLINE, EMBASE, CENTRAL, Scopus, PEDro (Physiotherapy Evidence Database), CNKI, SinoMed, and WANFANG databases from January 2000 to April 2020. Only randomized controlled trials were included. The authors independently screened the literature. The main outcome measures were focused on pain and physical function. A meta-analysis was performed on the collected data. Review Manager (RevMan, version 5.3) was used for all analyses.

Results

The systematic review identified 6 randomized controlled trials, 4 of which were included in the meta-analysis, comprising a total of 791 patients with knee OA. The meta-analysis with the fixed-effects model showed that the internet-based rehabilitation programs could significantly alleviate the osteoarthritic pain for patients compared with conventional rehabilitation (standardized mean difference [SMD] –0.21, 95% CI  −0.4 to –0.01, P=.04). No significant difference was found in the improvement of physical function in patients with knee OA compared with conventional rehabilitation within 2 to 12 months (SMD –0.08, 95% CI −0.27 to 0.12, P=.43).

Conclusions

This systematic review shows that internet-based rehabilitation programs could improve the pain but not physical function for patients with knee OA. However, there was a very small number of studies that could be included in the review and meta-analysis. Thus, further studies with large sample sizes are warranted to promote the effectiveness of internet-based rehabilitation and to develop its personalized design.

Stroke in Africa: profile, progress, prospects and priorities

Stroke is a leading cause of disability, dementia and death worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability occur in low-income and middle-income countries. At the turn of the century, the most common diseases in Africa were communicable diseases, whereas non-communicable diseases, including stroke, were considered rare, particularly in sub-Saharan Africa. However, evidence indicates that, today, Africa could have up to 2-3-fold greater rates of stroke incidence and higher stroke prevalence than western Europe and the USA. In Africa, data published within the past decade show that stroke has an annual incidence rate of up to 316 per 100,000, a prevalence of up to 1,460 per 100,000 and a 3-year fatality rate greater than 80%. Moreover, many Africans have a stroke within the fourth to sixth decades of life, with serious implications for the individual, their family and society. This age profile is particularly important as strokes in younger people tend to result in a greater loss of self-worth and socioeconomic productivity than in older individuals. Emerging insights from research into stroke epidemiology, genetics, prevention, care and outcomes offer great prospects for tackling the growing burden of stroke on the continent. In this article, we review the unique profile of stroke in Africa and summarize current knowledge on stroke epidemiology, genetics, prevention, acute care, rehabilitation, outcomes, cost of care and awareness. We also discuss knowledge gaps, emerging priorities and future directions of stroke medicine for the more than 1 billion people who live in Africa.

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.

Towards evidence-based policies to strengthen acute stroke care in low-middle-income countries

Stroke is a major public health issue in many low- and middle-income countries (LMICs). Despite the emergence of new effective interventions for acute stroke care, uptake remains slow and largely inaccessible to patients in LMICs, where health systems response has been inadequate. In this paper, we propose a policy framework to optimise access to acute stroke care in LMICs. We draw on evidence from relevant primary studies, such as availability of evidence-based acute stroke care interventions, barriers to uptake of interventions for stroke care and insights on stroke mortality and morbidity burden in LMICs. Insights from review of secondary studies, principally systematic reviews on evidence-based acute stroke care; and the accounts and experiences of some regional experts on stroke and other NCDs have been taken into consideration. In LMICs, there is limited availability and access to emergency medical transport services, brain imaging services and best practice interventions for acute stroke care. Availability of specialist acute stroke workforce and low awareness of early stroke signs and symptoms are also major challenges impeding the delivery of quality stroke care services. As a result, stroke care in LMICs is patchy, fragmented and often results in poor patient outcomes. Reconfiguration of LMIC health systems is thus required to optimise access to quality acute stroke care. We therefore propose a ten-point framework to be adapted to country-specific health system capacity, needs and resources: Emergency medical transport and treatment services, scaling-up interventions and services for acute stroke care, clinical guidelines for acute stroke treatment and management, access to brain imaging services, human resource capacity development strategies, centralisation of stroke services, tele-stroke care, public awareness campaigns on early stroke symptoms, establish stroke registers and financing of stroke care in LMICs. While we recognise the challenges of implementing the recommendations in low resource settings, this list can provide a platform as well serve as the starting point for advocacy and prioritisation of interventions depending on context.

COVID-19 and stroke: Experience in a Ghanaian healthcare system

Background

The novel coronavirus disease 19 (COVID-19) causes multi-system disease including possibly heightened stroke risk. Data from high-income countries (HIC) suggest disruptions to care delivery with reduced stroke admissions and administration of acute stroke reperfusion therapies. We are unaware of any published data on the impact of the COVID-19 pandemic on stroke admissions and outcomes in sub-Saharan Africa.

Purpose

To compare rates of stroke admissions and case fatality between corresponding periods in 2020 and 2019, within a hospital system in Ghana, to assess the potential impact of the COVID-19 pandemic.

Methods

We compared monthly stroke admissions and mortality rates between January to June 2020 vs. January to June 2019 at the Komfo Anokye Teaching Hospital, a tertiary medical center in Ghana. Predictors of in-patient mortality were assessed using a multivariate logistic regression model.

Results

Stroke admissions were higher in January to June 2020 vs. January to June 2019 (431 vs. 401), an increase of +7.5% (95% CI: 5.1–10.5%). There was also a rise in recurrent stroke admissions in 2020 vs. 2019 (19.0% vs. 10.9%, p = .0026). Stroke case fatality trended higher in 2020 vs. 2019 (29.3% vs. 24.2%, p = .095) with an adjusted odds ratio of 1.22 (95% CI: 0.89–1.68).

Conclusion

While an influence of secular trends cannot be excluded, the COVID-19 outbreak coincided with a comparatively significant rise in initial and recurrent stroke admissions at this Ghanaian tertiary hospital. Continued surveillance at this hospital, as well as assessment of this issue at other sites in Africa is warranted.

•

7.5% increase in stroke admissions.

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10% rise in recurrent stroke admissions.

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5% higher stroke case fatality.

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.

The Effect of Home Base Physical Activity Program based on the BASNEF Model on Motor Recovery in Patients with Stroke

The present study aimed to determine the effect of education based on the BASNEF model on the physical activity and improvement of motor activity in patients with stroke. This randomized control trial study was conducted on 40 patients with acute ischemic stroke admitted to a teaching hospital in Isfahan, Iran from August 2017 to September 2018. The patients were randomly divided into intervention and control groups. The intervention included personal education and a manual CD of physical activity for the intervention group. After education, the mean scores of the BASNEF model's constructs in the intervention group were significantly higher than those of the control group (P < .001). Furthermore, the motor ability of the intervention group in upper and lower extremities was significantly higher than that of the control group (p < .001). Interventions based on educational models can increase the motivation of patients with stroke in performing recommended physical activity.

Improving the quality of care for people who had a stroke in a low-/middle-income country: A qualitative analysis of health-care professionals' perspectives

BACKGROUND AND OBJECTIVE

Efforts to improve the adoption of evidence-based interventions for optimal patient outcomes in low-/middle-income countries (LMICs) are persistently hampered by a plethora of barriers. Yet, little is known about strategies to address such barriers to improve quality stroke care. This study seeks to explore health professionals' views on strategies to improve quality stroke care for people who had a stroke in a LMIC.

METHODS

A qualitative interview study design was adopted. A semi-structured interview guide was used to conduct in-depth interviews among forty stroke care providers in major referral centres in Ghana. Participants were from nursing, medical, specialist and allied health professional groups. A purposive sample was recruited to share their views on practical strategies to improve quality stroke care in clinical settings. A thematic analysis approach was utilized to inductively analyse the data.

RESULTS

A number of overarching themes of strategies to improve quality stroke care were identified: computerization and digitization of medical practice, allocation of adequate resources, increase the human resource capacity to deliver stroke care, development of clinical guideline/treatment protocols, institutionalization of multidisciplinary care and professional development opportunities. These strategies were however differentially prioritized among different categories of stroke care providers.

CONCLUSION

Closing the gap between existing knowledge on how to improve quality of stroke care in LMICs has the potential to be successful if unique and context-specific measures from the views of stroke care providers are considered in developing quality improvement strategies and health systems and policy reforms. However, for optimal outcomes, further research into the effectiveness and feasibility of the proposed strategies by stroke care providers is needed.

Teleassessment of Gait and Gait Aids: Validity and Interrater Reliability

BACKGROUND

Gait and mobility aid assessments are important components of rehabilitation. Given the increasing use of telehealth to meet rehabilitation needs, it is important to examine the feasibility of such assessments within the constraints of telerehabilitation.

OBJECTIVE

The objective of this study was to examine the reliability and validity of the Tinetti Performance-Oriented Mobility Assessment gait scale (POMA-G) and cane height assessment under various video and transmission settings to demonstrate the feasibility of teleassessment.

DESIGN

This repeated-measures study compared the test performances of in-person, slow motion (SM) review, and normal-speed (NS) video ratings at various fixed frame rates (8, 15, and 30 frames per second) and bandwidth (128, 384, and 768 kB/s) configurations.

METHODS

Overall bias, validity, and interrater reliability were assessed for in-person, SM video, and NS video ratings, with SM video rating as the gold standard, as well as for different frame rate and bandwidth configurations within NS videos.

RESULTS

There was moderate to good interrater reliability for the POMA-G (intraclass correlation coefficient [ICC] = 0.66-0.77 across all configurations) and moderate validity for in-person (β = 0.62; 95% confidence interval [CI] = 0.37-0.87) and NS video (β = 0.74; 95% CI = 0.67-0.80) ratings compared with the SM video rating. For cane height, interrater reliability was good (ICC = 0.66-0.77), although it was significantly lower at the lowest frame rate (8 frames per second) (ICC = 0.66; 95% CI = 0.54-0.76) and bandwidth (128 kB/s) (ICC = 0.69; 95% CI = 0.57-0.78) configurations. Validity for cane height was good for both in-person (β = 0.80; 95% CI = 0.62-0.98) and NS video (β = 0.86; 95% CI = 0.81-0.90) ratings compared with SM video rating.

LIMITATIONS

Some lower frame rate and bandwidth configurations may limit the reliability of remote cane height assessments.

CONCLUSIONS

Teleassessment for POMA-G and cane height using typically available internet and video quality is feasible, valid, and reliable.

Barriers and Facilitators to the Implementation of eHealth Services: Systematic Literature Analysis

Background

The field of eHealth has a history of more than 20 years. During that time, many different eHealth services were developed. However, factors influencing the adoption of such services were seldom the main focus of analyses. For this reason, organizations adopting and implementing eHealth services seem not to be fully aware of the barriers and facilitators influencing the integration of eHealth services into routine care.

Objective

The objective of this work is to provide (1) a comprehensive list of relevant barriers to be considered and (2) a list of facilitators or success factors to help in planning and implementing successful eHealth services.

Methods

For this study, a twofold approach was applied. First, we gathered experts’ current opinions on facilitators and barriers in implementing eHealth services via expert discussions at two health informatics conferences held in Europe. Second, we conducted a systematic literature analysis concerning the barriers and facilitators for the implementation of eHealth services. Finally, we merged the results of the expert discussions with those of the systematic literature analysis.

Results

Both expert discussions (23 and 10 experts, respectively) identified 15 barriers and 31 facilitators, whereas 76 barriers and 268 facilitators were found in 38 of the initial 56 articles published from 12 different countries. For the analyzed publications, the count of distinct barriers reported ranged from 0 to 40 (mean 10.24, SD 8.87, median 8). Likewise, between 0 and 48 facilitators were mentioned in the literature (mean 9.18, SD 9.33, median 6). The combination of both sources resulted in 77 barriers and 292 facilitators for the adoption and implementation of eHealth services.

Conclusions

This work contributes a comprehensive list of barriers and facilitators for the implementation and adoption of eHealth services. Addressing barriers early, and leveraging facilitators during the implementation, can help create eHealth services that better meet the needs of users and provide higher benefits for patients and caregivers.

Post-intervention qualitative assessment of mobile health technology to manage hypertension among Ghanaian stroke survivors

Stroke is a leading cause of death in Africa and a key modifiable risk factor for the index and recurrent stroke is through the adequate management of blood pressure. Recent guidelines encourage management beyond clinic settings, yet implementation of these guidelines can be challenging, especially in resource constrained regions, such as in Sub-Saharan Africa. Mobile health technology may offer an innovative and cost-effective approach to improve BP monitoring and facilitate adherence to antihypertensive medications. Stroke survivors (n = 16) and their caregivers (n = 8) who participated in a 3-month feasibility study were invited to share post-intervention insights via focus groups (n = 3). Clinician (n = 7) input on intervention delivery and clinical impressions was also obtained via a separate focus group (n = 1). Four major themes emerged highlighting the ability to self-monitor, the use of technology as an interventional tool, training and support, and post-intervention adherence. Overwhelming receptivity toward home blood pressure monitoring and the use of mobile health (mHealth) was noted. Feedback indicated benefits in having access to equipment and that message prompts facilitated adherence. Post-intervention adherence declined following study intervention, indicating a need for increased exposure to facilitate long-term behavioral change, although participants conveyed a heightened awareness of the importance of BP monitoring and lifestyle changes needed.

Rehabilitation in Low-Resource Areas

Earlier rehabilitation interventions, like community-based rehabilitation (CBR), could not make a remarkable impact because they ran parallel to the health system, but the newer model establishes health-related rehabilitation as an integral part of the health care system at all levels and thus should be implemented as such. Collaborating with other players relevant to the CBR matrix, such as social and vocational services, can be imparted for the empowerment of a disabled group at the village level through the CBR center. A multipurpose rehabilitation worker, through skill transfer or task shifting, can start rehabilitation at the primary health center.

The Sub-Saharan Africa Conference on Stroke (SSACS): An idea whose time has come

Stroke is a leading cause of global morbidity and mortality. Sub-Saharan Africa (SSA), where an unprecedented rise in stroke burden is currently raging, has the highest age-standardized stroke incidence, stroke prevalence, and stroke mortality rates. This is in sharp contrast to the relative decline in stroke incidence in high-income countries over the past four decades through better awareness and control of vascular risk factors. Compared to other groups, Africans tend to have a higher risk of stroke, higher percentage of the hemorrhagic type and much poorer outcomes. Indeed, stroke levies a heavy toll on the developing SSA economy by affecting a relatively younger age group. In this commentary, we examine the disproportionately high burden of stroke in the setting of grossly inadequate resources and evidence-based interventions. We propose an annual pan-regional stroke conference (starting in 2020) to harness global resources and local talent with the goal of galvanizing action to tackle this escalating burden. We anticipate that a successful conference series could become a rallying point for the eventual establishment of an African Stroke Organization.

Prevalence, Trajectory, and Predictors of Poststroke Fatigue among Ghanaians

BACKGROUND AND PURPOSE

Poststroke fatigue (PSF) is rife among stroke survivors and it exerts a detrimental toll on recovery from functional deficits. The burden of PSF is unknown in sub-Saharan Africa. We have assessed the prevalence, trajectory, and predictors of PSF among 60 recent Ghanaian stroke patients.

METHODS

Study participants in this prospective cohort (recruited between January 2017 and June 2017) were stroke survivors, aged greater than 18 years, with CT scan confirmed stroke of less than 1-month onset. PSF was assessed using the Fatigue Severity Scale (FSS) at enrollment, months 3, 6, and 9. Those with a score of greater than or equal to 4 points on FSS were categorized as "fatigued." A multivariate logistic regression analysis was performed to identify independent predictors of PSF at enrollment and at month 9.

RESULTS

Sixty-five percent (65%) of our sample were males with a mean age of 55.1 ± 12.7 years. In addition to all participants having hypertension, 85% had dyslipidemia and 25% had diabetes mellitus. Ischemic strokes comprised 76.6% of the study population. The prevalence of PSF was 58.9% at baseline and declined to 23.6% at month 9, P = .0002. Diabetes mellitus was significantly associated with PSF at baseline with an adjusted odds ratio of 15.12 (95% CI: 1.70-134.30), P = .01. However, at month 9, age greater than or equal to 65 years, adjusted odds ratio (aOR) of 7.02 (95% CI: 1.16-42.52); female sex, aOR of 8.52 (1.23-59.16), and depression, aOR of 8.86 (1.19-65.88) were independently associated with PSF.

CONCLUSIONS

Approximately 6 out of 10 Ghanaian stroke survivors experience PSF within the first month of stroke onset. PSF persists in approximately 1 out of 4 stroke survivors at 10 months after the index stroke. Further studies to elucidate the underlying mechanisms for PSF are required and adequately powered interventional multicenter trials are eagerly awaited to provide solid evidence base for the clinical management of PSF.

Estimated glomerular filtration rate predicts incident stroke among Ghanaians with diabetes and hypertension

Background

Sub-Saharan Africa is currently experiencing a high burden of both chronic kidney disease (CKD) and stroke as a result of a rapid rise in shared common vascular risk factors such as hypertension and diabetes mellitus. However, no previous study has prospectively explored independent associations between CKD and incident stroke occurrence among indigenous Africans. This study sought to fill this knowledge gap.

Methods

A prospective cohort study involving Ghanaians adults with hypertension or type II diabetes mellitus from 5 public hospitals. Patients were followed every 2 months in clinic for 18 months and assessed clinically for first ever stroke by physicians. Serum creatinine derived estimated glomerular filtration rates (eGFR) were determined at baseline for 2631 (81.7%) out of 3296 participants. We assessed associations between eGFR and incident stroke using a multivariate Cox Proportional Hazards regression model.

Results

Stroke incidence rates (95% CI) increased with decreasing eGFR categories of 89, 60–88, 30–59 and <29 ml/min corresponding to incidence rates of 7.58 (3.58–13.51), 14.45 (9.07–21.92), 29.43 (15.95–50.04) and 66.23 (16.85–180.20)/1000 person-years respectively. Adjusted hazard ratios (95%CI) for stroke occurrence according to eGFR were 1.42 (0.63–3.21) for eGFR of 60-89 ml/min, 1.88 (1.17–3.02) for 30-59 ml/min and 1.52 (0.93–2.43) for <30 ml/min compared with eGFR of >89 ml/min. Adjusted HR for stroke occurrence among patients with hypertension with eGFR<60 ml/min was 3.69 (1.49–9.13), p = .0047 and among those with diabetes was 1.50 (0.56–3.98), p = .42.

Conclusion

CKD is dose-dependently associated with occurrence of incident strokes among Ghanaians with hypertension and diabetes mellitus. Further studies are warranted to explore interventions that could attenuate the risk of stroke attributable to renal disease among patients with hypertension in SSA.

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We assessed association between incident stroke and estimated glomerular filtration rate.

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2631 participants stroke-free Ghanaian adults with hypertension or diabetes were followed for 14 months.

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There were 45 incident strokes.

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Incident stroke risk independently increased with declining eGFR.

Telerehabilitation for Stroke Survivors: Systematic Review and Meta-Analysis

Background

Telerehabilitation is an emerging technology through which medical rehabilitation care can be provided from a distance.

Objective

This systematic review and meta-analysis aims to investigate the efficacy of telerehabilitation in poststroke patients.

Methods

Eligible randomized controlled trials (RCTs) were identified by searching MEDLINE, Cochrane Central, and Web of Science databases. Continuous data were extracted for relevant outcomes and analyzed using the RevMan software as the standardized mean difference (SMD) and 95% CI in a fixed-effect meta-analysis model.

Results

We included 15 studies (1339 patients) in our systematic review, while only 12 were included in the pooled analysis. The combined effect estimate showed no significant differences between the telerehabilitation and control groups in terms of the Barthel Index (SMD –0.05, 95% CI –0.18 to 0.08), Berg Balance Scale (SMD –0.04, 95% CI –0.34 to 0.26), Fugl-Meyer Upper Extremity (SMD 0.50, 95% CI –0.09 to 1.09), and Stroke Impact Scale (mobility subscale; SMD 0.18, 95% CI –0.13 to 0.48]) scores. Moreover, the majority of included studies showed that both groups were comparable in terms of health-related quality of life (of stroke survivors), Caregiver Strain Index, and patients’ satisfaction with care. One study showed that the cost of telerehabilitation was lower than usual care by US $867.

Conclusions

Telerehabilitation can be a suitable alternative to usual rehabilitation care in poststroke patients, especially in remote or underserved areas. Larger studies are needed to evaluate the health-related quality of life and cost-effectiveness with the ongoing improvements in telerehabilitation networks.

Tele-Rehabilitation after Stroke: An Updated Systematic Review of the Literature

BACKGROUND

Tele-rehabilitation for stroke survivors has emerged as a promising intervention for remotely supervised administration of physical, occupational, speech, and other forms of therapies aimed at improving motor, cognitive, and neuropsychiatric deficits from stroke.

OBJECTIVE

We aimed to provide an updated systematic review on the efficacy of tele-rehabilitation interventions for recovery from motor, higher cortical dysfunction, and poststroke depression among stroke survivors.

METHODS

We searched PubMed and Cochrane library from January 1, 1980 to July 15, 2017 using the following keywords: "Telerehabilitation stroke," "Mobile health rehabilitation," "Telemedicine stroke rehabilitation," and "Telerehabilitation." Our inclusion criteria were randomized controlled trials, pilot trials, or feasibility trials that included an intervention group that received any tele-rehabilitation therapy for stroke survivors compared with a control group on usual or standard of care.

RESULTS

This search yielded 49 abstracts. By consensus between 2 investigators, 22 publications met the criteria for inclusion and further review. Tele-rehabilitation interventions focused on motor recovery (n = 18), depression, or caregiver strain (n = 2) and higher cortical dysfunction (n = 2). Overall, tele-rehabilitation interventions were associated with significant improvements in recovery from motor deficits, higher cortical dysfunction, and depression in the intervention groups in all studies assessed, but significant differences between intervention versus control groups were reported in 8 of 22 studies in favor of tele-rehabilitation group while the remaining studies reported nonsignificant differences.

CONCLUSION

This updated systematic review provides evidence to suggest that tele-rehabilitation interventions have either better or equal salutary effects on motor, higher cortical, and mood disorders compared with conventional face-to-face therapy.

Estimating the uptake of brain imaging and 30-days stroke mortality in Nigeria: A meta-analysis of hospital-based studies

PURPOSE

This study aims to estimate the computed tomography (CT) and Magnetic resonance imaging (MRI) uptake, stroke subtypes and 30-days case-fatality in Nigeria.

METHODS

Stroke diagnosis and mortality data were identified from relevant databases. A random effect meta-analysis was conducted to obtain the pooled percentage uptake of CT/MRI, including 30-days case fatality and a meta-regression-like epidemiological model was applied on all data points.

FINDINGS

A total of 24 studies involving 5874 stroke patients conducted in predominantly tertiary referral hospitals met the inclusion criteria. The pooled CT/MRI uptake in the last seven years was 46.66% (95% CI = 15.35 to 77.98, 8 studies). There were significant variations in the prevalence of stroke subtypes. The pooled prevalence ischemic stroke was highest (55.32%, 95% CI 48.67 to 61.97, 16 studies), followed by intracerebral haemorrhage (ICH) (32.69%, 95% CI 25.54 to 39.83, 16 studies), subarachnoid haemorrhage (SAH) (3.76%, 95% CI 2.30 to 5.22, 14 studies). In addition, the stroke of undetermined aetiology was found to be 16.57% (95% CI, 7.44-25.70, 8 studies). Overall, the 24-h, one-week and 30-days case-fatality from stroke were 10.84% (95% CI, 4.48-17.20), 24.62% (95% CI, 17.20-32.04) and 33.28% (95% CI, 27.80-38.77), respectively. There was a moderate negative correlation between prevalence of brain imaging uptake and ischaemic stroke, albeit not statistically significant (Spearman rho = 0.333, p-value = .412).

CONCLUSION

Uptake of CT/MRI procedure for stroke is poor in Nigeria. Although poverty, inaccessibility and influence of major risk factors remain pronounced, scaling up of effective strategies for stroke prevention and management should be a major public health policy priority in Nigeria.

Pilot trial of a tele-rehab intervention to improve outcomes after stroke in Ghana: A feasibility and user satisfaction study

BACKGROUND

Tele-rehabilitation after stroke holds promise for under-resourced settings, especially sub-Saharan Africa (SSA), with its immense stroke burden and severely limited physical therapy services.

OBJECTIVE

To preliminarily assess the feasibility and outcomes of mobile technology-assisted physical therapy exercises for stroke survivors in Ghana.

METHODS

We conducted a prospective, single arm, pre-post study involving 20 stroke survivors recruited from a tertiary medical center, who received a Smartphone with the 9zest Stroke App® to deliver individualized, goal-targeted 5-days-a-week exercise program that was remotely supervised by a tele-therapist for 12 weeks. Outcome measures included changes in stroke levity scale scores (SLS), Modified Rankin score (MRS), Montreal Cognitive Assessment (MOCA), and feasibility indicators.

RESULTS

Among study participants, mean ± SD age was 54.6 ± 10.2 years, 11 (55%) were men, average time from stroke onset was 6 months. No participants dropped out. Compared with baseline status, mean ± SD scores on SLS improved from 7.5 ± 3.1 to 11.8 ± 2.2 at month 1 (p < 0.0001) and 12.2 ± 2.4 at month 3 (p < 0.0001), MOCA scores improved from 18.2 ± 4.3 to 20.4 ± 4.7 at month 1 (p = 0.14), and 22.2 ± 7.6 at month 3 (p = 0.047). Mean ± SD weekly sessions performed by participants per month was 5.7 ± 5.8 and duration of sessions was 25.5 ± 16.2 min. Erratic internet connectivity negatively affected full compliance with the intervention, although satisfaction ratings by study participants were excellent.

CONCLUSION

It is feasible to administer an m-health delivered physical therapy intervention in SSA, with high user satisfaction. Randomized trials to assess the efficacy and cost-effectiveness of this intervention are warranted.

Long-Term Outcomes of Stroke in a Ghanaian Outpatient Clinic

BACKGROUND

Compared with high-income countries, sub-Saharan African (SSA) countries experience a comparatively higher early mortality from stroke. However, data on long-term mortality from stroke in SSA are lacking.

OBJECTIVE

Our aim is to assess long-term outcomes of stroke in an SSA setting.

METHODS

We conducted a retrospective analysis of longitudinal data involving 607 consecutive stroke survivor encountered at an outpatient clinic in Kumasi, Ghana, between January 2012 and June 2014. Data were closed for analysis in June 2016. Data on demography, presence of vascular risk factors, stroke type, and functional status were evaluated. We followed up subjects who were no longer attending clinic by phone to assess their vital status. Primary outcome was death after initiation of clinic care, and its predictors were determined using a Cox proportional hazards regression model.

RESULTS

Mean ± standard deviation (SD) age of cohort was 59.9 ± 13.9 years and 50.3% were female. Of the 607 stroke survivors, 377 (62.1%) were still alive, 59 (9.7%) were confirmed to have died, whereas 171 (28.2%) were lost to follow-up at the clinic. Mean ± SD observation time for the cohort was 32 ± 30 months. Upon adjustment for confounders, the independent predictors of mortality were age (adjusted hazard ratio [aHR] of 1.41 [95% confidence interval 1.15-1.73] for a 10-year increase in age) and diabetes mellitus (aHR of 2.24 [1.32-3.80]).

CONCLUSIONS

Diabetes mellitus, a modifiable risk factor for stroke, is associated with an increased risk of mortality among West African stroke survivors over the long term.