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

Effectiveness of integrated care models for stroke patients: A systematic review and meta-analysis

INTRODUCTION

Given that stroke is a leading cause of disability and mortality worldwide, there is an urgent need for a coordinated healthcare approach to mitigate its effects. The objectives of this study were to perform a systematic review and meta-analysis of stroke integrated care models and develop recommendations for a representative model.

DESIGN

A systematic review and meta-analysis.

METHODS

The literature search identified randomized controlled trials comparing integrated care models with standard care for stroke patients. The included studies followed PICOs inclusion criteria. The qualitative analysis included creating a flowchart for the literature screening process, and tables detailing the basic characteristics of the included studies, the adherence to the ten principles and the results of the quality assessments. Subsequently, quantitative meta-analytical procedures were conducted to statistically pool the data and quantify the effects of the integrated care models on stroke patients' health-related quality of life, activities of daily living, and depression. The China National Knowledge Infrastructure (CNKI), Wanfang Data, Chongqing VIP Chinese Science and Technology Periodical Database (VIP), China Biology Medicine Disc (CBMDISC), Cochrane Library, Cumulated Index to Nursing and Allied Health Literature (CINAHL), PubMed, Web of Science, Embase, Google Scholar, and Clinical Trials were searched from inception to March 13, 2024.

RESULTS

Of the 2547 obtained articles, 19 were systematically reviewed and 15 were included in the meta-analysis. The integrated care models enhanced stroke patients' health-related quality of life, ability to perform activities of daily living, and reduced depression. Adherence to the 10 principles varied: comprehensive services, patient focus, and standardized care delivery had strong implementation, while gaps were noted in geographic coverage, information systems, governance structures, and financial management.

CONCLUSION

Integrated care models improve outcomes for stroke patients and adherence to the 10 principles is vital for their implementation success. This study's findings call for a more standardized approach to implementing integrated care models, emphasizing the need for integrated services, patient-centred care, and interdisciplinary collaboration, while also addressing the identified gaps in terms of integration efforts.

CLINICAL RELEVANCE

This study provides evidence-based recommendations on the most effective integrated care approaches for stroke patients, potentially leading to better patient outcomes, reduced healthcare costs, and improved quality of life.

Research, education and practice of tele-neurorehabilitation in low and middle-income countries: A Scoping Review

BACKGROUND

Tele-neurorehabilitation (TNR) allows for remote delivery of rehabilitation services for those with neurological disabilities. Despite growing global interest and uptake, its adoption remains challenging in Low-and-Middle-Income-Countries (LMICs).

OBJECTIVE

To explore available literature on the nature of training and education, research and practice of TNR in LMICs.

METHODS

Following PRISMA-ScR guidelines and predefined selection criteria, four databases were screened. Quality assessment was performed using the Joanna Briggs Institute tools. Relevant data was extracted to using a data extraction form in Microsoft Excel and were narratively synthesised under Education/training, Research and Clinical Practice of TNR.

RESULTS

We identified no formal structured training courses/programs for TNR users/providers. Sessions were mainly delivered as part of a research project. The included studies highlighted the need to engage stakeholders in TNR research and improve digital-literacy among healthcare providers/users. Development and use of clinical decision-making-tools, models of TNR suitable for varied populations and prior area-mapping were a few suggestions for clinical/research practice.

CONCLUSION

There is an immense need to develop academic/structured programs for TNR to build capacity among providers/users in LMICs. Practice must adhere to principles of safety, effectiveness, and based on high quality clinical-guidelines suitable to the context to ensure optimal uptake and practice of TNR in LMICs.

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.

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.

Mobile health applications for improving physical function, physical activity, and quality of life in stroke survivors: a systematic review

PURPOSE

To evaluate the effectiveness of mobile health applications (mHealth apps) containing a physical training component on physical function and physical activity in stroke rehabilitation.

MATERIALS AND METHODS

A systematic literature search was conducted in three databases for studies published from inception to 12 July 2022. Clinical trials including mHealth apps with a physical training component were included using outcomes of physical function and physical activity. Quality of life was extracted as a secondary outcome.

RESULTS

Five RCTs, two non-RCTs, and four uncontrolled clinical trials were included with a total of 264 stroke survivors. Eleven apps were identified with a physical training component using features of gamification (six apps), exercise prescription (three apps), and physical activity (two apps). Six out of seven studies reported statistically significant improvements in physical function in favor of the experimental group, with the most robust findings for upper extremity function. For physical activity, statistically significant improvements were seen in the experimental groups. Only one study showed significant improvement in quality of life. Overall study quality was fair.

CONCLUSIONS

mHealth apps containing a physical training component are promising for physical function and physical activity in stroke rehabilitation. Further research is warranted to confirm these conclusions.Implications for rehabilitationDesign content of mobile apps with a physical training component were focused on gamification, exercise prescription, and physical activityUsing mobile app-delivered therapy seem promising for improving upper extremity function in stroke rehabilitationUsing mobile apps also supported an increase of physical activity in people with strokeStudies using mobile apps should report more specifically the dosage of physical training and adherenceUsing mobile apps seems promising as an additional tool for clinical work, however, more studies are required to understand their effectiveness in stroke rehabilitation.

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.

Mobile App Interventions for Parkinson's Disease, Multiple Sclerosis and Stroke: A Systematic Literature Review

Central nervous system diseases (CNSDs) lead to significant disability worldwide. Mobile app interventions have recently shown the potential to facilitate monitoring and medical management of patients with CNSDs. In this direction, the characteristics of the mobile apps used in research studies and their level of clinical effectiveness need to be explored in order to advance the multidisciplinary research required in the field of mobile app interventions for CNSDs. A systematic review of mobile app interventions for three major CNSDs, i.e., Parkinson's disease (PD), multiple sclerosis (MS), and stroke, which impose significant burden on people and health care systems around the globe, is presented. A literature search in the bibliographic databases of PubMed and Scopus was performed. Identified studies were assessed in terms of quality, and synthesized according to target disease, mobile app characteristics, study design and outcomes. Overall, 21 studies were included in the review. A total of 3 studies targeted PD (14%), 4 studies targeted MS (19%), and 14 studies targeted stroke (67%). Most studies presented a weak-to-moderate methodological quality. Study samples were small, with 15 studies (71%) including less than 50 participants, and only 4 studies (19%) reporting a study duration of 6 months or more. The majority of the mobile apps focused on exercise and physical rehabilitation. In total, 16 studies (76%) reported positive outcomes related to physical activity and motor function, cognition, quality of life, and education, whereas 5 studies (24%) clearly reported no difference compared to usual care. Mobile app interventions are promising to improve outcomes concerning patient's physical activity, motor ability, cognition, quality of life and education for patients with PD, MS, and Stroke. However, rigorous studies are required to demonstrate robust evidence of their clinical effectiveness.

Scoping review of health information technology usability methods leveraged in Africa

OBJECTIVE

The aim of this study was to explore the state of health information technology (HIT) usability evaluation in Africa.

MATERIALS AND METHODS

We searched three electronic databases: PubMed, Embase, and Association for Computing Machinery. We categorized the stage of evaluations, the type of interactions assessed, and methods applied using Stead's System Development Life Cycle (SDLC) and Bennett and Shackel's usability models.

RESULTS

Analysis of 73 of 1002 articles that met inclusion criteria reveals that HIT usability evaluations in Africa have increased in recent years and mainly focused on later SDLC stage (stages 4 and 5) evaluations in sub-Saharan Africa. Forty percent of the articles examined system-user-task-environment (type 4) interactions. Most articles used mixed methods to measure usability. Interviews and surveys were often used at each development stage, while other methods, such as quality-adjusted life year analysis, were only found at stage 5. Sixty percent of articles did not include a theoretical model or framework.

DISCUSSION

The use of multistage evaluation and mixed methods approaches to obtain a comprehensive understanding HIT usability is critical to ensure that HIT meets user needs.

CONCLUSIONS

Developing and enhancing usable HIT is critical to promoting equitable health service delivery and high-quality care in Africa. Early-stage evaluations (stages 1 and 2) and interactions (types 0 and 1) should receive special attention to ensure HIT usability prior to implementing HIT in the field.

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.

Effect of mobile application types on stroke rehabilitation: a systematic review

BACKGROUND

Stroke is a significant contributor of worldwide disability and morbidity with substantial economic consequences. Rehabilitation is a vital component of stroke recovery, but inpatient stroke rehabilitation programs can struggle to meet the recommended hours of therapy per day outlined by the Canadian Stroke Best Practices and American Heart Association. Mobile applications (apps) are an emerging technology which may help bridge this deficit, however this area is understudied. The purpose of this study is to review the effect of mobile apps for stroke rehabilitation on stroke impairments and functional outcomes. Specifically, this paper will delve into the impact of varying mobile app types on stroke rehabilitation.

METHODS

This systematic review included 29 studies: 11 randomized control trials and 18 quasi-experimental studies. Data extrapolation mapped 5 mobile app types (therapy apps, education apps, rehab videos, reminders, and a combination of rehab videos with reminders) to stroke deficits (motor paresis, aphasia, neglect), adherence to exercise, activities of daily living (ADLs), quality of life, secondary stroke prevention, and depression and anxiety.

RESULTS

There were multiple studies supporting the use of therapy apps for motor paresis or aphasia, rehab videos for exercise adherence, and reminders for exercise adherence. For permutations involving other app types with stroke deficits or functional outcomes (adherence to exercise, ADLs, quality of life, secondary stroke prevention, depression and anxiety), the results were either non-significant or limited by a paucity of studies.

CONCLUSION

Mobile apps demonstrate potential to assist with stroke recovery and augment face to face rehabilitation, however, development of a mobile app should be carefully planned when targeting specific stroke deficits or functional outcomes. This study found that mobile app types which mimicked principles of effective face-to-face therapy (massed practice, task-specific practice, goal-oriented practice, multisensory stimulation, rhythmic cueing, feedback, social interaction, and constraint-induced therapy) and education (interactivity, feedback, repetition, practice exercises, social learning) had the greatest benefits. Protocol registration PROPSERO (ID CRD42021186534). Registered 21 February 2021.

mHealth in sub-Saharan Africa and Europe: A systematic review comparing the use and availability of mHealth approaches in sub-Saharan Africa and Europe

Background

mHealth can help with healthcare service delivery for various health issues, but there's a significant gap in the availability and use of mHealth systems between sub-Saharan Africa and Europe, despite the ongoing digitalization of the global healthcare system.

Objective

This work aims to compare and investigate the use and availability of mHealth systems in sub-Saharan Africa and Europe, and identify gaps in current mHealth development and implementation in both regions.

Methods

The study adhered to the PRISMA 2020 guidelines for article search and selection to ensure an unbiased comparison between sub-Saharan Africa and Europe. Four databases (Scopus, Web of Science, IEEE Xplore, and PubMed) were used, and articles were evaluated based on predetermined criteria. Details on the mHealth system type, goal, patient type, health concern, and development stage were collected and recorded in a Microsoft Excel worksheet.

Results

The search query produced 1020 articles for sub-Saharan Africa and 2477 articles for Europe. After screening for eligibility, 86 articles for sub-Saharan Africa and 297 articles for Europe were included. To minimize bias, two reviewers conducted the article screening and data retrieval. Sub-Saharan Africa used SMS and call-based mHealth methods for consultation and diagnosis, mainly for young patients such as children and mothers, and for issues such as HIV, pregnancy, childbirth, and child care. Europe relied more on apps, sensors, and wearables for monitoring, with the elderly as the most common patient group, and the most common health issues being cardiovascular disease and heart failure.

Conclusion

Wearable technology and external sensors are heavily used in Europe, whereas they are seldom used in sub-Saharan Africa. More efforts should be made to use the mHealth system to improve health outcomes in both regions, incorporating more cutting-edge technologies like wearables internal and external sensors. Undertaking context-based studies, identifying determinants of mHealth systems use, and considering these determinants during mHealth system design could enhance mHealth availability and utilization.

Long-term determinants of death after stroke in Ghana: Analysis by stroke types & subtypes

BACKGROUND

Determinants of long-term mortality after stroke by mechanistic type and subtype are unknown in sub-Saharan Africa (SSA). Such data are crucial for targeting specific pathophysiologic pathways to improve stroke outcomes in the region.

PURPOSE

To evaluate rates and predictors of mortality up to 8 years after stroke, by type and subtype, in Ghana.

METHODS

We prospectively collected data on stroke patients presenting at a tertiary medical facility in Ghana between 2013 and 2018 who were followed up until October 31, 2021. Stroke diagnosis was confirmed using a Computerized Tomography scan; ischemic strokes were mechanistically typed using the TOAST classification while intracerebral hemorrhages were subtyped using the SMASH-U scheme. Demographic and clinical predictors of stroke mortality were evaluated using Cox proportional hazards regression modelling.

RESULTS

Of 564 patients encountered during the study period, data on vital status were available for 556 (98.6%) subjects at discharge and 442 (78.4%) on follow-up. Mean age was 61.1 ±15.1 years, and 223 (53.1%) were male. Mortality rates at 1, 3, 12, 36, 60 and 96 months were 37.5%, 43.2%, 49.7%, 57.4%, 62.9%, and 73.7% respectively. Three (3) factors remained significantly associated with risk of death namely age, adjusted hazard ratios (aHR) of 1.12 (95%CI: 1.04-1.20), no formal education 1.36 (95% CI: 1.02-1.81) and modified Rankin score 1.67 (95%CI: 1.42 - 1.98) for each unit rise. For ischemic stroke the four (4) factors associated with long-term mortality were low formal education, low monthly income, having diabetes mellitus and higher functional score on admission. For intracerebral hemorrhage, the two factors were increasing age and high functional score.

CONCLUSION

Stroke severity is the key predictor of long-term mortality after an index stroke in Ghana, regardless of the underlying pathophysiologic mechanism. Instituting acute stroke systems of care to facilitate timely reperfusion efforts may greatly improve long term survival outcomes after stroke in SSA.

Telerehabilitation of Post-Stroke Patients with Motor Function Disorders: A Review

Stroke is the main reason for disabilities of increasing geriatric population. It affects brain and motor function domains significantly reducing the life quality. Recent coronavirus pandemic raised a question on changing approaches to deliver post-stroke rehabilitation services to geriatric patients due to their high risk of serious illness. This paper presents an overview of current telerehabilitation approaches for motor function recovery and balance training of post-stroke patients. We used papers from peer-reviewed medical journals on stroke telerehabilitation. The review showed exergames, virtual reality (VR), web-platforms, and applications are extensively used in rehabilitation programs to gain clinical outcomes among geriatric stroke patients. Findings indicate telerehabilitation improves older patients’ functional ability via systematic training, positively affecting their life quality. The treatment therapy of older adults using telerehabilitation can be organized synchronously and asynchronously in home-based environment or in-clinic conditions. Telerehabilitation can be used as complementary therapy or as an alternative to conventional treatment. However, further research is required to test a variety of telerehabilitation systems using larger samples of post-stroke geriatric patients.

Provision and use of physical rehabilitation services for adults with disabilities in Rwanda: A descriptive study

Background

Physical rehabilitation interventions address functional deficits caused by impairments that affect someone’s performance. Whilst rehabilitation is important, it is assumed that these services are either minimal or nonexistent in low-resource settings. Our data expand on the data from the Situation Assessment of Rehabilitation in the Republic of Rwanda report to describe rehabilitation services and who access them at public and semiprivate facilities (primarily funded by the private sector).

Objectives

This article describes the use of the outpatient physical rehabilitation services across nine health facilities, the characteristics of adults attending these health facilities and some of the facilitators and barriers they encounter when attending rehabilitation.

Method

Data were collected between September and December 2018 from the heads of departments and adult patients attending outpatient rehabilitation services funded by the government, international nongovernmental organisations or faith-based organisations.

Results

Two hundred and thirteen adults were recruited from nine facilities. There is a sixfold difference in the number of rehabilitation personnel between public and semiprivate hospitals in these facilities’ catchment areas. However, most participants were recruited at public facilities (186 [87%]), primarily with physical disorders. Patients reported that family support (94%) was the most crucial facilitator for attending rehabilitation, whilst transportation cost (96%) was a significant barrier.

Conclusion

Rehabilitation service availability for Rwandan adults with disabilities is limited. Whilst family support helps patients attend rehabilitation, transportation costs remain a significant barrier to people attending rehabilitation. Strategies to address these issues include developing triage protocols, training community health workers and families.

Contribution

Data on rehabilitation service provision in Rwanda and most African countries are either non-existent or very limited. These data contain important information regarding the services provided and the people who used them across different health facilities (public versus private) and urban versus rural settings). To improve rehabilitation service provision, we first need to understand the current situation. These data are an important step to better understanding rehabilitation in Rwanda.

Recent trends in telerehabilitation of stroke patients: A narrative review

BACKGROUND: Stroke is the main reason for disabilities worldwide leading to motor dysfunction, spatial neglect and cognitive problems, aphasia, and other speech-language pathologies, reducing the life quality. To overcome disabilities, telerehabilitation (TR) has been recently introduced. OBJECTIVE: The aim of this review was to analyze current TR approaches for stroke patients’ recovery. METHODS: We searched 6 online databases from January 2018 to October 2021, and included 70 research and review papers in the review. We analyzed TR of 995 individuals, which was delivered synchronously and asynchronously. RESULTS: Findings show TR is feasible improving motor function, cognition, speech, and language communication among stroke patients. However, the dose of TR sessions varied significantly. We identified the following limitations: lack of equipment, software, and space for home-based exercises, insufficient internet capacity and speed, unavailability to provide hands on guidance, low digital proficiency and education, high cognitive demand, small samples, data heterogeneity, and no economic evaluation. CONCLUSIONS: The review shows TR is superior or similar to conventional rehabilitation in clinical outcomes and is used as complementary therapy or as alternative treatments. More importantly, TR provides access to rehabilitation services of a large number of patients with immobility, living in remote areas, and during COVID-19 pandemic or similar events.

Current Management of Acute Ischemic Stroke in Africa: A Review of the Literature

BACKGROUND

Acute ischemic stroke is one of the leading causes of disability and mortality globally, with increasing incidence in Africa, as the continent is already burdened with infectious diseases. Rapid diagnosis and efficient treatment are crucial, as even a slight delay to reperfuse the brain significantly affects the recovery outcome. Neuroimaging is vital for optimal care and thrombolytic or endovascular therapy in specialised stroke care units. This review aims to discuss the burden of acute ischemic stroke in Africa and how healthcare systems have tried to reduce the incidence and improve outcomes for the disease.

METHODOLOGY

Data was collected from online databases and medical journal published on PubMed, Ovid MEDLINE, ScienceDirect and Embase bibliographical data. All articles related to acute ischemic stroke in Africa were considered.

RESULTS

The medical care for acute ischemic stroke in Africa is far from optimal with little adherence to recommended protocols. There is a lack of public awareness of the disease, imaging infrastructure, personnel, stroke care units and recovery facilities, due to poor funding. Poor knowledge of stroke signs and symptoms results in delay in treatment and poor prognosis.

CONCLUSION

We urge African leaders and private entities to invest in stroke care by building appropriate infrastructures, providing medical equipments, implementing guidelines, and sustainable follow-up systems. Telehealth is a suggested strategy to mitigate the scarcity of health personnel, and international and national efforts to increase treatment affordability should be doubled. Further extensive research on the impact of acute ischemic stroke on the African continent population is encouraged.

Accuracy and Validity of a Single Inertial Measurement Unit-Based System to Determine Upper Limb Kinematics for Medically Underserved Populations

Stroke is one of the leading causes of death and disability worldwide, with a disproportionate burden represented by low- and middle-income countries (LMICs). To improve post-stroke outcomes in LMICs, researchers have sought to leverage emerging technologies that overcome traditional barriers associated with stroke management. One such technology, inertial measurement units (IMUs), exhibit great potential as a low-cost, portable means to evaluate and monitor patient progress during decentralized rehabilitation protocols. As such, the aim of the present study was to determine the ability of a low-cost single IMU sensor-based wearable system (named the T’ena sensor) to reliably and accurately assess movement quality and efficiency in physically and neurologically healthy adults. Upper limb movement kinematics measured by the T’ena sensor were compared to the gold standard reference system during three functional tasks, and root mean square errors, Pearson’s correlation coefficients, intraclass correlation coefficients, and the Bland Altman method were used to compare kinematic variables of interest between the two systems for absolute accuracy and equivalency. The T’ena sensor and the gold standard reference system were significantly correlated for all tasks and measures (r range = 0.648—0.947), although less so for the Finger to Nose task (r range = 0.648—0.894). Results demonstrate that single IMU systems are a valid, reliable, and objective method by which to measure movement kinematics during functional tasks. Context-appropriate enabling technologies specifically designed to address barriers to quality health services in LMICs can accelerate progress towards the United Nations Sustainable Development Goal 3.

Telerehabilitation in response to constrained physical distance: an opportunity to rethink neurorehabilitative routines

Ensuring proper dosage of treatment and repetition over time is a major challenge in neurorehabilitation. However, a requirement of physical distancing to date compromises their achievement. While mostly associated to COVID-19, physical distancing is not only required in a pandemic scenario, but also advised for several clinical conditions (e.g. immunocompromised individuals) or forced for specific social contexts (e.g. people living in remote areas worldwide). All these contexts advocate for the implementation of alternative healthcare models. The objective of this perspective is to highlight the benefits of remote administration of rehabilitative treatment, namely telerehabilitation, in counteracting physical distancing barriers in neurorehabilitation. Sustaining boosters of treatment outcome, such as compliance, sustainability, as well as motivation, telerehabilitation may adapt to multiple neurological conditions, with the further advantage of a high potential for individualization to patient's or pathology's specificities. The effectiveness of telerehabilitation can be potentiated by several technologies available to date: virtual reality can recreate realistic environments in which patients may bodily operate, wearable sensors allow to quantitatively monitor the patient's performance, and signal processing may contribute to the prediction of long-term dynamics of patient recovery. Telerehabilitation might spark its advantages far beyond the mere limitation of physical distancing effects, mitigating criticalities of daily neurorehabilitative practice, and thus paving the way to the envision of mixed models of care, where hospital-based procedures are complementarily integrated with telerehabilitative ones.

The 2021 William Feinberg Award Lecture Seeking Glocal Solutions to Cerebrovascular Health Inequities

Global and local (“glocal”) disparities in stroke incidence, prevalence, care, and mortality are persistent, pervasive, and progressive. In particular, the disproportionate burden of stroke in people of African ancestry compared to most other racial/ethnic groups around the world has been long standing, is expected to worsen, and so far, has defied solution, largely because conventional risk factors likely account for less than half of the Black versus White disparity in stroke outcomes. While hypotheses such as a differential impact or inadequate evaluation of traditional risk factors by race have been suggested as potentially key factors contributing to lingering racial/ethnic stroke disparities, relatively understudied novel risk factors such as psychosocial stress, environmental pollution, and inflammation; and influences of the social determinants of health are gaining the most attention (and momentum). Moreover, it is increasingly recognized that while there is a lot still to understand, there needs to be a major shift from incessantly studying the problem, to developing interventions to resolve it. Resolution will likely require targeting multilevel factors, considering contemporaneous cross-national and cross-continental data collection, creating scalable care delivery models, jointly addressing care quality and community drivers of stroke occurrence, incorporating policy makers in planning/dissemination of successful interventions, and investing in robust transdisciplinary research training programs that address the interrelated issues of health equity and workforce diversity, and regional capacity building. To this end, our international multidisciplinary team has been involved in conducting several epidemiological studies and clinical trials in the area of stroke disparities, as well as executing career enhancing research training programs in the United States and Africa. This award lecture paper shares some of the lessons we have learnt from previous studies, presents objectives/design of ongoing initiatives, and discusses plans for the future.

Evaluation of a Newly Developed Smartphone App for Risk Factor Management in Young Patients With Ischemic Stroke: A Pilot Study

Background: Efficient treatment of modifiable vascular risk factors decreases reoccurrence of ischemic stroke, which is of uttermost importance in younger patients. In this longitudinal pilot study, we thus assessed the effect of a newly developed smartphone app for risk factor management in such a cohort. Methods: The app conveys key facts about stroke, provides motivational support for a healthy lifestyle, and a reminder function for medication intake and blood pressure measurement. Between January 2019 and February 2020, we consecutively invited patients with ischemic stroke aged between 18 and 55 years to participate. Patients in the intervention group used the app between hospital discharge and 3-month follow-up. The control group received standard clinical care. Modifiable risk factors (physical activity, nutrition, alcohol consumption, smoking behavior, obesity, and hypertension) were assessed during the initial hospital stay and at a dedicated stroke outpatient department three months post-stroke. Results: The study cohort comprised 21 patients in the app intervention group (62% male; age = 41 ± 11 years; education = 12 ± 3 years) and 21 sex-, age- and education-matched control patients with a comparable stroke risk factor profile. Baseline stroke severity was comparable between groups (intervention: median NIHSS = 3; control: median NIHSS = 4; p = 0.604). Three months post-stroke, patients in the intervention group reported to be physically almost twice as active (13 ± 9 h/week) compared to controls (7 ± 5 h/week; p = 0.022). More intense app usage was strongly associated with higher physical activity (r = 0.60, p = 0.005) and lower consumption of unhealthy food (r = -0.51, p = 0.023). Smoking behavior (p = 0.001) and hypertension (p = 0.003) improved in all patients. Patients in the intervention group described better self-reported health-related quality of life three months post-stroke (p = 0.003). Conclusions: Specifically designed app interventions can be an easily to implement and cost-efficient approach to promote a healthier lifestyle in younger patients with a stroke.

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.

Home-Based Tele-Exercise in Musculoskeletal Conditions and Chronic Disease: A Literature Review

Exercise training is an essential component in the treatment or rehabilitation of various diseases and conditions. However, barriers to exercise such as the burdens of travel or time may hinder individuals' ability to participate in such training programs. Advancements in technology have allowed for remote, home-based exercise training to be utilized as a supplement or replacement to conventional exercise training programs. Individuals in these home-based exercise programs are able to do so under varying levels of supervision from trained professionals, with some programs having direct supervision, and others having little to no supervision at all. The purpose of this review is to examine the use of home-based, tele-exercise training programs for the treatment of different disease states and conditions, and how these programs compare to conventional clinic-based exercise training programs.

Tele-Neurorehabilitation During the COVID-19 Pandemic: Implications for Practice in Low- and Middle-Income Countries

The importance of neurorehabilitation services for people with disabilities is getting well-recognized in low- and middle-income countries (LMICs) recently. However, accessibility to the same has remained the most significant challenge, in these contexts. This is especially because of the non-availability of trained specialists and the availability of neurorehabilitation centers only in urban cities owned predominantly by private healthcare organizations. In the current COVID-19 pandemic, the members of the Task Force for research at the Indian Federation of Neurorehabilitation (IFNR) reviewed the context for tele-neurorehabilitation (TNR) and have provided the contemporary implications for practicing TNR during COVID-19 for people with neurological disabilities (PWNDs) in LMICs. Neurorehabilitation is a science that is driven by rigorous research-based evidence. The current pandemic implies the need for systematically developed TNR interventions that is evaluated for its feasibility and acceptability and that is informed by available evidence from LMICs. Given the lack of organized systems in place for the provision of neurorehabilitation services in general, there needs to be sufficient budgetary allocations and a sector-wide approach to developing policies and systems for the provision of TNR services for PWNDs. The pandemic situation provides an opportunity to optimize the technological innovations in health and scale up these innovations to meet the growing burden of neurological disability in LMICs. Thus, this immense opportunity must be tapped to build capacity for safe and effective TNR services provision for PWNDs in these settings.

Unravelling 'low-resource settings': a systematic scoping review with qualitative content analysis

INTRODUCTION

The effects of healthcare-related inequalities are most evident in low-resource settings. Such settings are often not explicitly defined, and umbrella terms which are easier to operationalise, such as 'low-to-middle-income countries' or 'developing countries', are often used. Without a deeper understanding of context, such proxies are pregnant with assumptions, insinuate homogeneity that is unsupported and hamper knowledge translation between settings.

METHODS

A systematic scoping review was undertaken to start unravelling the term 'low-resource setting'. PubMed, Africa-Wide, Web of Science and Scopus were searched (24 June 2019), dating back ≤5 years, using terms related to 'low-resource setting' and 'rehabilitation'. Rehabilitation was chosen as a methodological vehicle due to its holistic nature (eg, multidisciplinary, relevance across burden of disease, and throughout continuum of care) and expertise within the research team. Qualitative content analysis through an inductive approach was used.

RESULTS

A total of 410 codes were derived from 48 unique articles within the field of rehabilitation, grouped into 63 content categories, and identified nine major themes relating to the term 'low-resource setting'. Themes that emerged relate to (1) financial pressure, (2) suboptimal healthcare service delivery, (3) underdeveloped infrastructure, (4) paucity of knowledge, (5) research challenges and considerations, (6) restricted social resources, (7) geographical and environmental factors, (8) human resource limitations and (9) the influence of beliefs and practices.

CONCLUSION

The emerging themes may assist with (1) the groundwork needed to unravel 'low-resource settings' in health-related research, (2) moving away from assumptive umbrella terms like 'low-to-middle-income countries' or 'low/middle-income countries' and (3) promoting effective knowledge transfer between settings.

Telerehabilitation of Post-Stroke Patients as a Therapeutic Solution in the Era of the Covid-19 Pandemic

(1) Background: Due to the pandemic caused by the SARS-CoV-2 virus, rehabilitation centres have become less available for neurological patients. This is the result of efforts to physically distance society, to try to slow the spread of the pathogen. Health care facilities were mainly restricted to urgent cases, while most physiotherapy treatments, mainly for patients with chronic conditions, were suspended. Some countries have seen a reduction in acute stroke hospital admissions of from 50% to 80%. One solution to the above problem is the use of telerehabilitation in the home environment as an alternative to inpatient rehabilitation. (2) Aim of the study: The purpose of this review is to analyse the benefits and limitations of teletherapy in relation to the functional condition of post-stroke patients. (3) Methods: Selected publications from 2019 to 2021 on the telerehabilitation of stroke patients were reviewed. The review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. (4) Results: Studies have proven that teletherapy significantly improves the functional condition of post-stroke patients, resulting in improved quality of life and faster return to independence (while maintaining maximum possible precautions related to the SARS-CoV-2 virus pandemic). (5) Conclusions: Analysis of the study results showed comparable effectiveness of rehabilitation in the tele system to inpatient therapy. However, it should be emphasised that patients undergoing telerehabilitation must meet strict conditions to be eligible for this type of treatment program. However, the strength of the evidence itself supporting the effectiveness of this method ranks low due to the limited number of randomised control trials (RCT), small number of participants, and heterogeneous trials.

Telerehabilitation in response to constrained physical distance: an opportunity to rethink neurorehabilitative routines

Ensuring proper dosage of treatment and repetition over time is a major challenge in neurorehabilitation. However, a requirement of physical distancing to date compromises their achievement. While mostly associated to COVID-19, physical distancing is not only required in a pandemic scenario, but also advised for several clinical conditions (e.g. immunocompromised individuals) or forced for specific social contexts (e.g. people living in remote areas worldwide). All these contexts advocate for the implementation of alternative healthcare models. The objective of this perspective is to highlight the benefits of remote administration of rehabilitative treatment, namely telerehabilitation, in counteracting physical distancing barriers in neurorehabilitation. Sustaining boosters of treatment outcome, such as compliance, sustainability, as well as motivation, telerehabilitation may adapt to multiple neurological conditions, with the further advantage of a high potential for individualization to patient's or pathology's specificities. The effectiveness of telerehabilitation can be potentiated by several technologies available to date: virtual reality can recreate realistic environments in which patients may bodily operate, wearable sensors allow to quantitatively monitor the patient's performance, and signal processing may contribute to the prediction of long-term dynamics of patient recovery. Telerehabilitation might spark its advantages far beyond the mere limitation of physical distancing effects, mitigating criticalities of daily neurorehabilitative practice, and thus paving the way to the envision of mixed models of care, where hospital-based procedures are complementarily integrated with telerehabilitative ones.

The characteristics of stroke and its rehabilitation in Northern Tanzania

BACKGROUND

Stroke causes great suffering and severe disability worldwide, and rehabilitation following a stroke seeks to restore lost functions. The extent to which stroke patients get access to rehabilitation in Tanzania is not well estimated, and drawing a current picture of the rehabilitation services for these persons is the first step in developing a more effective rehabilitation model in the country.

OBJECTIVE

The objective of this study was to establish the characteristics of stroke and its rehabilitation at the Kilimanjaro Christian Medical Centre (KCMC), a consultant referral hospital in northern Tanzania.

METHODS

This was a records-based descriptive study in which demographic, clinical, and rehabilitation information of stroke patients admitted to the KCMC between January 2012 and December 2015 was collected and audited. The means, percentages, and proportions were used to summarise the demographic, clinical, and rehabilitation patterns using SPSS version 24.0 software. The chi-squared statistic was used to examine the relationships between categorical variables, and a p-value<0.05 was considered statistically significant.

RESULTS

Of the 17,975 patients admitted to the KCMC during the period of the study, 753 (4.2%) had suffered a stroke, with a mean age of 68.8 ± 16.4 years. The predominant cause of stroke was hypertension, which accounted for 546 (72.5%) patients. A total of 357 (47.4%) patients had various forms of rehabilitation during the admission to hospital. Following a discharge home 240 (31.9%) patients did not return to the hospital for the continuation of rehabilitation.

CONCLUSION

Stroke patients at the KCMC lack access to rehabilitation therapies. Insufficient access to rehabilitation therapies may warrant the need to explore alternative approaches such as tele-rehabilitation technologies in Tanzania.

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.

mHealth applications to support caregiver needs and engagement during stroke recovery: A content review

Caregiving in stroke results in severe physical, psychological, and social impacts on the caregiver. Over the past few years, researchers have explored the use of mHealth technologies to support healthcare-related activities due to their ability to provide real-time care at any given place or time. The purpose of this content review is to investigate mHealth apps in supporting stroke caregiving engagement based on three aspects: motivation, value, and satisfaction. We searched app stores and repositories for apps related to stroke caregiving published up to September 2020. Extracted apps were reviewed and filtered using inclusion criteria, and then downloaded onto compatible devices to determine eligibility. Results were compared with evidence-based frameworks to identify the ability of these apps in engaging and supporting the caregiver. Forty-seven apps were included in this review that enabled caregivers to support their needs, such as adjustment to new roles and relationships, involvement in care and caring for oneself using several different functionalities. These functionalities include information resources, risk assessment, remote monitoring, data sharing, reminders and so on. However, no single app was identified that focuses on all aspects of stroke caregiving. We also identified several challenges faced by users through their reviews and the factors associated with value and satisfaction. Our findings can add to the knowledge of existing mHealth technologies and their functionalities to support stroke caregiving needs, and the importance of considering user engagement in the design. They can be used by developers and researchers looking to design better mHealth apps for stroke caregiving.

mHealth Intervention Applications for Adults Living With the Effects of Stroke: A Scoping Review

Objective

To conduct a scoping review of mobile health (mHealth) application (app) interventions to support needs of adults living with the effects of stroke reported in the literature.

Data Sources

PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus were systematically searched for peer-reviewed publications. Articles were published between January 2007 and September 2020 and met predefined inclusion and exclusion criteria.

Study Selection

Articles included were written in English language, involved adults older than 18 years, and described an mHealth app specifically tested and/or developed as an intervention for someone with stroke to be used remotely and/or independently without constant provider supervision or assistance. Articles were excluded if they focused on acute management of stroke only, focused on primary prevention, were animal studies, were not an app for smartphone or tablet, and did not describe an empirical study.

Data Extraction

Two researchers independently screened titles and abstracts for inclusion. The full-text articles were then reviewed for eligibility by the research team. Data were extracted and verified by a third reviewer.

Data Synthesis

The search yielded 2123 studies and 49 were included for data extraction. The findings reveal that a global surge of studies on mHealth apps for people with stroke have emerged within the past 2 years. Most studies were developed for persons with stroke in the United States and the primary content foci included upper extremity function (31.5%); lower extremity function (5.3%); general exercise, physical activity, and/or functional mobility (23.7%); trunk control (5.3%); medical management and secondary prevention (26.3%); language and speech skills (20.5%); cognitive skills (7.9%); general disability and activities of daily living (5.3%); and home safety (2.6%). Of the included studies, a majority were preliminary in nature, with 36.7% being categorized as pilot or feasibility trials and 24.4% discussing initial design, development, and/or refinement.

Conclusions

Results from this study reveal that the number of apps specifically developed for people with stroke and described in the scientific literature are growing exponentially. The apps have widely varied content to meet the needs of persons with stroke; however, the studies are generally preliminary in nature, focusing on development, usability, and initial pilot testing. This review highlights the need for additional research and development of mHealth apps targeted for adults with stroke. Development should consider the various and complex needs of people living with the effects of chronic stroke, while large-scale trials are needed to build on the existing evidence.

Development and Feasibility Testing of Video Home Based Telerehabilitation for Stroke Survivors in Resource Limited Settings

Tele-physiotherapy has been shown to be valuable to improve clinical outcomes after stroke. Yet, home-based interventions for stroke survivors (SSVs) who speak indigenous African languages are sparse. This study developed a video-based home exercise programme (VHEP) for SSV speakers of Yoruba. A qualitative descriptive pilot study was conducted in two phases: development and feasibility testing. VHEP development followed the American Stroke Association's recommendations to include demonstrations of task-specific mobility-task and postural training; trunk exercises, and overground walking. The exercise instructions were presented in the Yoruba language. Each exercise was demonstrated for five minutes on video for a total of 30 minutes. The feasibility testing involved ten consenting chronic SSVs. Each imitated the VHEP twice per week for two weeks and thereafter completed a feasibility questionnaire. Criteria for feasibility were: cost of using VHEP, recruitment rate, retention of participants, adherence to the exercises, and intervention delivery. The ten SSVs were recruited within one week, had prior home access to a video player at no-cost, adhered to the exercises as recorded, completed the 30 minute-duration for two weeks, and confirmed intervention delivery of VHEP. Most participants liked the novel use of Yoruba as the language of instruction on VHEP. The VHEP was feasible and acceptable among the studied sample of SSVs. Video based home telerehabilitation for SSVs therefore has the potential to meet the growing need for tele-physiotherapy in resource limited settings.

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.

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.

Low blood pressure levels & incident stroke risk among elderly Ghanaians with hypertension

BACKGROUND

Clinical trial data indicate that more intensive blood pressure (BP) lowering below standard cut-off targets is associated with lower risks of strokes in the elderly. There is a relative paucity of real-world practice data on this issue, especially among Africans.

OBJECTIVE

To assess BP control rates, its determinants, and whether a lower BP < 120/80 mmHg is associated with a lower incident stroke risk among elderly Ghanaians with hypertension.

METHODS

We retrospectively evaluated data, which were prospectively collected as part of a cohort study involving adults with hypertension and/or diabetes in 5 Ghanaian hospitals. BP control was defined using the JNC-8 guideline of <150/90 mmHg for elderly with hypertension aged >60 years or 140/90 mmHg for those with diabetes mellitus. Risk factors for poor BP control were assessed using multivariable logistic regression models. We calculated incident stroke risk over an 18-month follow-up at 3 BP cut-off's of <120/80, 120-159/80-99, and > 160/100 mmHg.

RESULTS

Of the 1365 elderly participants with hypertension, 38.2% had diabetes mellitus and 45.8% had uncontrolled BP overall. Factors associated with uncontrolled BP were higher number of antihypertensive medications prescribed adjusted odds ratio of 1.45 (95% CI: 1.27-1.66), and having diabetes 2.56 (1.99-3.28). Among the elderly, there were 0 stroke events/100py for BP < 120/80 mmHg, 1.98 (95%CI: 1.26-2.98) for BP between 120 and 159/80-99 mmHg and 2.46 events/100py (95% CI: 1.20-4.52 at BP > 160/100 mmHg.

CONCLUSION

A lower BP target <120/80 mmHg among elderly Ghanaians with hypertension is associated with a signal of lower incident stroke risk. Pragmatic trials are needed to evaluate lower BP targets on stroke incidence in Africa.

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.

[Use of smartphone apps in secondary stroke prevention]

Modifiable risk factors such as hypertension, obesity or smoking have been reported to explain up to 90% of risk for ischemic stroke. Treatment of these risk factors is known to decrease the risk of recurrent stroke events. We performed a computer-based literature research from June to August 2018 using the electronic database PubMed to investigate the effect of smartphone apps on risk factor control for secondary stroke prevention as well as feasibility and patient satisfaction with mobile health. Studies evaluating interventions by smartphone or tablet devices in stroke patients and reported results regarding risk factors, feasibility or patient satisfaction were considered (n = 10). Identified data showed significant improvement regarding the control of risk factors hypertension and diabetes as well as significant improvements of the lifestyle risk factors physical inactivity and obesity. Stroke patients perceive smartphone apps mostly as useful and are open-minded regarding mHealth, provided that these complement rather than replace personal medical care.

Self-management of non-communicable diseases in low- and middle-income countries: A scoping review

Background

The prevalence of non-communicable diseases (NCDs) is rising in low- and middle-income countries (LMICs). Self-management, which enables patients to better manage their health, presents a potentially-scalable means of mitigating the growing burden of NCDs in LMICs. Though the effectiveness of self-management interventions in high-income countries is well-documented, the use of these strategies in LMICs has yet to be thoroughly summarized.

Objective

The purpose of this scoping review is to summarize the nature and effectiveness of past interventions that have enabled the self-management of NCDs in LMICs.

Methods

Using the scoping review methodology proposed by Arksey and O’Malley, PubMed was searched for relevant articles published between January 2007 and December 2018. The implemented search strategy comprised three major themes: self-management, NCDs and LMICs.

Results

Thirty-six original research articles were selected for inclusion. The selected studies largely focused on the self-management of diabetes (N = 21), hypertension (N = 7) and heart failure (N = 5). Most interventions involved the use of short message service (SMS, N = 17) or phone calls (N = 12), while others incorporated educational sessions (N = 10) or the deployment of medical devices (N = 4). The interventions were generally effective and often led to improvements in physiologic indicators, patient self-care and/or patient quality of life. However, the studies emphasized results in small populations, with little indication of future scaling of the intervention. Furthermore, the results indicate a need for further research into the self-management of cardiovascular diseases, as well as for the co-management of diabetes and cardiovascular disease.

Conclusions

Self-management appears to be an effective means of improving health outcomes in LMICs. Future strategies should include patients and clinicians in all stages of design and development, allowing for a focus on long-term sustainability, scalability and interoperability of the intervention in the target setting.

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.

Telerehabilitation in individuals with severe acquired brain injury: Rationale, study design, and methodology

BACKGROUND

Severe acquired brain injury (SABI) rehabilitation should be as intensive and long as to allow the patients get the best independence and quality of life (QoL), but facing with the rehabilitation socioeconomic burden. Telerehabilitation (TR) could supply frail subjects requiring long-term rehabilitation.

METHODS

A multicenter, prospective, parallel design, single-blind trial will be conducted at the IRCCS Neurolesi Bonino Pulejo (Messina, Italy) and IRCCS Hospital San Camillo (Venice, Italy) involving patients suffering from SABI and requiring home motor and cognitive rehabilitation. We will investigate the use of TR, based on advanced Information and Communication Technology (ICT) solutions, taking into account that the supervision of rehabilitation at home will be enriched with the counseling and vital parameters monitoring. The enrolled patients will be balanced for pathology, and randomized in 2 groups, performing TR (G1) or standard rehabilitation training (G2), respectively, according to a pc-generated random assignment. TR will be delivered by means of an advanced video-conferencing system, whereas the patient will be provided with low-cost monitoring devices, able to collect data about his/her health status and QoL. In both the groups each treatment (either cognitive or motor, or both as per patient functional status) will last about 1 hour a day, 5 days/week, for 12 weeks. Two structured telephone interviews will be administered to the patients (when possible) and/or their caregivers, and to all the healthcare professionals involved in the patient management, 1 week after the beginning and at the end of the TR. All the patients will undergo a complete neurological and cognitive examination performed by skilled physicians and psychologists, blindly. Clinical evaluations will be administered blindly, before and after the treatments.

RESULTS

the data of this study should demonstrate that TR is at least non-inferior in comparison with the same amount of usual territorial rehabilitative physical treatments, taking into account patients' functional recovery, psychological well-being, caregiver burden, and healthcare costs.

CONCLUSION

data coming from this study could demonstrate the usefulness of TR in facing the rehabilitation socioeconomic burden of managing patients with SABI, so to allow the patients get the best independence and quality of life (QoL).

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.