Impact of post-stroke disability and disability-perception on health-related quality of life of stroke survivors: the moderating effect of disability-severity

Dynamic changes and lifetime effect of functional disability profiles for stroke patients: real-world evidence from South Korea

PURPOSE

This work aimed to investigate the long-term dynamic changes of functional disabilities and estimate lifetime outcomes of different functional disabilities after a stroke, using real-world data from a nationally representative South Korean cohort.

METHODS

Patients aged 18 and above with ischemic and hemorrhagic strokes were identified from the Korea Health Panel (KHP) data (2008-2018). Functional disabilities were repeatedly measured for patients aged 55 and over for the prevalence of disabilities associated with activities of daily living (ADL), and kernel smoothing means were estimated for each item. The lifetime survival function of stroke patients in Korea was adopted from another study utilizing the National Health Insurance Service of Korea's national sample cohort. By multiplying the disability-free proportion with the survival function throughout life, disability-free life expectancy (DFLE) for each ADL item was estimated. The loss-of-DFLE was calculated by subtracting the DFLE from age-, sex-, and calendar year-matched referents simulated from Korean life tables.

RESULTS

The KHP dataset included 466 stroke patients. The overall functional disability needs increased over time after stroke diagnosis. DFLE was lowest for bathing (10.1 years for ischemic stroke and 12.8 years for hemorrhagic stroke), followed by those for dressing and washing. Loss-of-DFLE was highest for bathing for ischemic and hemorrhagic strokes (7.2 and 10.7 years, respectively), indicating that this task required the most assistance for stroke patients compared with the other tasks. DFLEs were slightly lower than the quality-adjusted life expectancy of stroke patients.

CONCLUSION

Our findings provide valuable insights for resource allocation and policy decisions in long-term stroke care, potentially enhancing the quality of life for stroke survivors and caregivers.

Acceptance of disability in stroke: a systematic review

BACKGROUND

Evidence for the association between acceptance of disability (AOD) and positive rehabilitation outcomes, as well as for the use of AOD measurements in stroke rehabilitation practice, has increased in the international literature in the last decade. However, measurement tools for AOD are heterogenous and there has not been a systematic review summarizing the current evidence on the use of AOD measures and factors associated with AOD.

OBJECTIVE

This study aimed to summarize current evidence on measurement tools used, present existing AOD scores in people with stroke and identify risk factors for and protective factors against poor AOD in people with stroke.

METHODS

The original design and protocol of this systematic review were registered with PROSPERO. The included studies were published from 2008 to 2020 and identified from 5 databases-PubMed, EMBASE, CINAHL Plus, PsycInfo, and the Cochrane Library-using the following inclusion criteria: participants diagnosed with stroke and aged ≥16 years, measurement of AOD, and published in English in a peer-reviewed scientific journal. Review articles were excluded.

RESULTS

Five measurement tools for AOD were reported. The Revised Acceptance of Disability Scale (ADS-R) and the acceptance subscale of the Illness Cognition Questionnaire (ICQ) had the highest internal consistency. Scores ranged from 71.7 to 74.2 on the ADS-R, 16.9-18.3 on the ICQ, 16.5-26.9 on the Acceptance of Illness Scale, and 87.8-93.2 on the Attitudes towards Disabled Persons Form A. Poorer function and depressive symptoms were associated with poor AOD, whereas religious beliefs, support from others, and an understanding of stroke were associated with better AOD.

CONCLUSIONS

The ADS-R and the acceptance subscale of the ICQ are currently the most reliable measurement tools for measuring AOD in people with stroke. Further research to validate the measurement tools is required. This may help to identify people who require additional support.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42017077063; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=77063.

Barriers to Enrollment in a Post-Stroke Neuromodulation and Walking Study: Implications for Recruiting Women

BACKGROUND

Women have a higher risk of stroke and related disability than men but are underrepresented in stroke clinical trials. Identifying modifiable recruitment and enrollment barriers for women can improve study generalizability, statistical power, and resource utilization.

OBJECTIVE

In a post-stroke neuromodulation study, we determined the impact of sex on the occurrence of exclusion criteria and compared the sex distribution of screened and enrolled individuals with a broader stroke-affected population.

METHODS

A total of 335 individuals with chronic stroke were screened for a study examining how neuromodulation and high-intensity treadmill training affect walking speed and corticomotor excitability. Demographics and exclusions were retrospectively gathered as a secondary dataset. Exclusion criteria consisted of 6 categories (not target population, unable to do treadmill protocol, unable to do non-invasive brain stimulation, insufficient ankle motion and disinterest, and cognitive impairment). Incidence of each exclusion criterion was compared between women and men. The sex distribution was compared to a dataset from Chicago primary stroke centers.

RESULTS

A total of 81 individuals were enrolled and 254 were not. The percentage of women excluded was significantly greater than that of men (P = .04). No individual exclusion criterion or categories excluded women more frequently than men. Screened and enrolled individuals had a lower proportion of women and younger age than a representative stroke population (P < .001).

CONCLUSIONS

We identified exclusion criteria (ie, headaches, cognitive scores, and age) that are modifiable barriers to enrollment of women in this post-stroke neuromodulation study. Addressing underrepresentation of women in stroke research is pivotal for enhancing generalizability, achieving statistical power, and optimizing resources.

Why do some people with stroke not receive the recommended 45 min of occupational therapy and physiotherapy after stroke? A qualitative study using focus groups

OBJECTIVES

To generate qualitative data on the views of Occupational Therapists and Physiotherapists about why people do not receive the Royal College of Physicians' recommended minimum of 45 minutes (min) of daily therapy after stroke, in order to inform a Delphi study.

DESIGN

Focus group study.

SETTING

Stroke services in the South of England.

PARTICIPANTS

A total of nine participants, in two groups, including therapists covering inpatient and Early Supported Discharge (ESD) services with awareness of the 45 min guideline.

RESULTS

Thematic analysis of focus group data identified five factors that influence the amount of therapy a person receives: The Person (with stroke), Individual Therapist, Stroke Multidisciplinary Team, the Organisation and the Guideline. Study findings suggest that the reasons why a person does not receive the therapy recommendation in inpatient and ESD services relate to either the suitability of the guideline for the person with stroke, or the ability of the service to deliver the guideline.

CONCLUSION

This study provides evidence for possible reasons why some people do not receive a minimum of 45 minutes of therapy, 5 days per week, related to (1) the suitability of the guideline for people with stroke and (2) services' ability to deliver this amount of intervention. These two factors are related; therapists decide who should receive therapy and how much in the context of (a) resource availability and (b) people's need and the benefit they will experience. The study findings, combined with the findings from other studies, will be used to initiate a Delphi study, which will establish consensus among therapists regarding the reasons why some people do not receive the guideline amount of therapy.

Associations of effort-reward imbalance at work and quality of life among workers after stroke: a one-year longitudinal study in Thailand

Stroke incidence is increasing among working-age population, but the role of psychosocial stress in the workplace in predicting quality of life (QoL) after stroke onset is understudied. This longitudinal study aimed to investigate the relationship between work stress, measured by the effort-reward imbalance (ERI) model, and QoL over one-year period among 103 Thai workers who had experienced a stroke. The study evaluated the effort (E)-reward (R) ratio and over-commitment, the extrinsic and intrinsic components of the ERI model, before discharge; QoL was repeatedly measured at baseline, six months, and 12 months after discharge, respectively, using the Short Form Version 2 (SF-12v2) indicators of physical and mental health composite scores. Generalized estimating equations were used to examine longitudinal relationships between work stress at baseline and QoL over one year by testing the hypotheses that E-R ratio and over-commitment would have direct effects on QoL, and potential moderating effects of over-commitment on E-R ratio and QoL. The results supported the ERI model partially, as over-commitment was significantly associated with poor mental health (coefficient - 8.50; 95% CI: -13.79, -3.20) after adjusting baseline sociodemographic, behavioral, and clinical characteristics, while the E-R ratio was not significantly associated with physical or mental health; the interaction between the E-R ratio and over-commitment was also not significant. These findings suggest that more attention should be paid to workers' personal coping skills and ability to handle work-related problems and prioritize interventions that address over-commitment to promote long-term mental health among workers with stroke.

Validity of the telematic Fugl Meyer assessment scale - upper extremity (TFMA-UE) Spanish version

Background

Telematic assistance has become indispensable in recent years. The increased prevalence of Acquired brain injury and the sequels it causes, requires long-lasting multidisciplinary treatments. Validated tools to assess the evolution of the disabilities and limitations of this pathology are essential to individualize and prescribe adapted treatments. The aim has been to create the telematic version of the Fugl Meyer Assessment-Upper Extremity Motor Function (TFMA-UE) Spanish scale and its adaptation to the remote assessment of neurologic patients.

Methods

An adapted scale was designed based on the Fugl Meyer Assessment scale-telematic version (FMA-TV): TFMA-UE. This scale is composed by 21 items which evaluate the upper extremity motor function. Physiotherapists trained in this tool, evaluate the results obtained from applying the two versions (on-site and telematic) to compare the results.

Results

TFMA-UE was administered to 30 patients with acquired brain injury. It was applied on site and through the web platform selected by the patients in two different days. Patients completed all the scale in an easily way without help. The exploratory and confirmatory factor analysis confirmed a factorial structure with a factor (76.08% of the variance). The Cronbach's internal consistency index obtained was 0.98 and the weight kappa index used to measure agreement between the two versions was 0.78 which represents substantial agreement.

Conclusion

The Telematic Fugl Meyer Assessment-Upper Extremity Motor Function (TFMA-UE) scale is a viable, useful and easy to apply tool that allows the upper extremity motor function assessment of Acquired Brain Injury patients.

Postoperative Disability and One-Year Outcomes for Patients Suffering a Stroke after Carotid Endarterectomy

OBJECTIVES

Although post-carotid endarterectomy (CEA) strokes are rare, they can be devastating. The degree of disability that patients develop after such events and its effects on long-term outcomes are unclear. Our goal was to assess the extent of postoperative disability in patients suffering strokes after CEA and evaluate its association with long-term outcomes.

METHODS

The Vascular Quality Initiative CEA registry (2016-2020) was queried for CEAs performed for asymptomatic or symptomatic indications in patients with preoperative modified Rankin Scale (mRS) scores of 0-1. The mRS grades stroke-related disability as 0 (none), 1 (not significant), 2-3 (moderate), 4-5 (severe), and 6 (dead). Patients suffering postoperative strokes with recorded mRS scores were included. Postoperative stroke-related disability based on mRS and its association with long-term outcomes were analyzed.

RESULTS

Among 149,285 patients undergoing CEA, there were 1,178 patients without preoperative disability who had postoperative strokes and reported mRS scores. Mean age was 71 ± 9.2 years and 59.6% of patients were male. Regarding ipsilateral cortical symptoms within six months preoperatively, 83.5% of patients were asymptomatic, 7.3% had transient ischemic attacks, and 9.2% had strokes. Postoperative stroke-related disability was classified as mRS 0 (11.6%), 1 (19.5%), 2-3 (29.4%), 4-5 (31.5%), and 6 (8%). One-year survival stratified by postoperative stroke-related disability was 91.4% for mRS 0, 95.6% for mRS 1, 92.1% for mRS 2-3, and 81.5% for mRS 4-5 (P<.001). Multivariable analysis demonstrated that while severe postoperative disability was associated with increased death at one year (HR 2.97, 95% CI 1.5-5.89, P=.002), moderate postoperative disability had no such association (HR .95, 95% CI .45-2, P=.88). One-year freedom from subsequent ipsilateral neurological events or death stratified by postoperative stroke-related disability was 87.8% for mRS 0, 93.3% for mRS 1, 88.5% for mRS 2-3, and 77.9% for mRS 4-5 (P<.001). Severe postoperative disability was independently associated with increased ipsilateral neurological events or death at one year (HR 2.34, 95% CI 1.25-4.38, P=.01). However, moderate postoperative disability exhibited no such association (HR .92, 95% CI .46-1.82, P=.8).

CONCLUSIONS

The majority of patients without preoperative disability who suffered strokes after CEA developed significant disability. Severe stroke-related disability was associated with higher one-year mortality and subsequent neurological events. These data can improve informed consent for CEA and guide prognostication after postoperative strokes.

Variations in Health-Related Quality of Life After Stroke: Insights From a Clinical Trial on Arm Rehabilitation With a Long-Term Follow-Up

Despite rehabilitation, stroke patients continue to have impaired function and reduced health-related quality of life (HRQoL) even in a chronic stage. However, no clear information is available on long-term variations in HRQoL. In this study, we aimed to report the short- and long-term changes in HRQoL in a subacute stroke sample that was enrolled in a clinical trial on arm rehabilitation. Thirty-nine stroke survivors (62% male, mean age 68 years) were assessed using the Stroke Impact Scale Version 2.0 (SIS 2.0) pre and post rehabilitation and at 6 months and 6 years follow-up. Long-term changes in physical function were explored through clinically meaningful changes in the Stroke Impact Scale-16 (SIS-16). After rehabilitation (P < .001), an overall improvement was found in all SIS domains except the memory and thinking, emotions, and communication domains. The baseline SIS-16 score (P < .001), the presence of a sensory deficit, and rehabilitation setting (P < .05) were factors related to the SIS-16 domain scores at the end of rehabilitation and at 6 months follow-up. Patients showed the most deterioration in the mobility (P < .001), strength (P < .003), and hand function (P < .05) domains 6 years after stroke. Stroke severity, male gender, and age ⩾65 years are related with a long-term HRQoL reduction after stroke.

Current Status of Acceptance of Disability and the Correlation With the Life Quality in Parkinson's Disease in Southwest China

Background

Acceptance of disability (AOD) is a process that a patient must undergo to cope with altered abilities, but its effect in Parkinson's disease (PD) remains unclear. The present study aimed to determine the level of AOD, examine the influence of sociodemographic variables and disease characteristics on the AOD level, and evaluate the relation between AOD level and quality of life in a cohort of PD patients from Southwest of China.

Methods

A total of 336 PD patients were consecutively recruited from November 2018 to October 2020. At enrollment, demographic and clinical data were obtained using a questionnaire, and the Acceptance of Disability Scale-Revised (AODS-R) scale was used to measure the AOD level.

Results

The mean total score of AOD is 87.28, indicating a moderate level of disability acceptance in PD patients. Statistical analysis showed that understanding of PD, family support, and UPDRS-II score were major factors affecting AOD level, and patients with low AOD levels were more likely to have poorer quality of life.

Conclusion

AOD is a serious problem in PD patients in Southwest China, especially among individuals with insufficient family support and a lack of recognition of the disease. AOD was also associated with motor function and daily living ability, thus suggesting that evaluation of the AOD and promotion of the awareness may be helpful to improve the quality of life in patients with PD.

The effect of time spent in rehabilitation on activity limitation and impairment after stroke

BACKGROUND

Stroke affects millions of people every year and is a leading cause of disability, resulting in significant financial cost and reduction in quality of life. Rehabilitation after stroke aims to reduce disability by facilitating recovery of impairment, activity, or participation. One aspect of stroke rehabilitation that may affect outcomes is the amount of time spent in rehabilitation, including minutes provided, frequency (i.e. days per week of rehabilitation), and duration (i.e. time period over which rehabilitation is provided). Effect of time spent in rehabilitation after stroke has been explored extensively in the literature, but findings are inconsistent. Previous systematic reviews with meta-analyses have included studies that differ not only in the amount provided, but also type of rehabilitation.

OBJECTIVES

To assess the effect of 1. more time spent in the same type of rehabilitation on activity measures in people with stroke; 2. difference in total rehabilitation time (in minutes) on recovery of activity in people with stroke; and 3. rehabilitation schedule on activity in terms of: a. average time (minutes) per week undergoing rehabilitation, b. frequency (number of sessions per week) of rehabilitation, and c. total duration of rehabilitation.

SEARCH METHODS

We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, eight other databases, and five trials registers to June 2021. We searched reference lists of identified studies, contacted key authors, and undertook reference searching using Web of Science Cited Reference Search.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adults with stroke that compared different amounts of time spent, greater than zero, in rehabilitation (any non-pharmacological, non-surgical intervention aimed to improve activity after stroke). Studies varied only in the amount of time in rehabilitation between experimental and control conditions. Primary outcome was activities of daily living (ADLs); secondary outcomes were activity measures of upper and lower limbs, motor impairment measures of upper and lower limbs, and serious adverse events (SAE)/death.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies, extracted data, assessed methodological quality using the Cochrane RoB 2 tool, and assessed certainty of the evidence using GRADE. For continuous outcomes using different scales, we calculated pooled standardised mean difference (SMDs) and 95% confidence intervals (CIs). We expressed dichotomous outcomes as risk ratios (RR) with 95% CIs.

MAIN RESULTS

The quantitative synthesis of this review comprised 21 parallel RCTs, involving analysed data from 1412 participants.  Time in rehabilitation varied between studies. Minutes provided per week were 90 to 1288. Days per week of rehabilitation were three to seven. Duration of rehabilitation was two weeks to six months. Thirteen studies provided upper limb rehabilitation, five general rehabilitation, two mobilisation training, and one lower limb training. Sixteen studies examined participants in the first six months following stroke; the remaining five included participants more than six months poststroke. Comparison of stroke severity or level of impairment was limited due to variations in measurement. The risk of bias assessment suggests there were issues with the methodological quality of the included studies. There were 76 outcome-level risk of bias assessments: 15 low risk, 37 some concerns, and 24 high risk. When comparing groups that spent more time versus less time in rehabilitation immediately after intervention, we found no difference in rehabilitation for ADL outcomes (SMD 0.13, 95% CI -0.02 to 0.28; P = 0.09; I2 = 7%; 14 studies, 864 participants; very low-certainty evidence), activity measures of the upper limb (SMD 0.09, 95% CI -0.11 to 0.29; P = 0.36; I2 = 0%; 12 studies, 426 participants; very low-certainty evidence), and activity measures of the lower limb (SMD 0.25, 95% CI -0.03 to 0.53; P = 0.08; I2 = 48%; 5 studies, 425 participants; very low-certainty evidence). We found an effect in favour of more time in rehabilitation for motor impairment measures of the upper limb (SMD 0.32, 95% CI 0.06 to 0.58; P = 0.01; I2 = 10%; 9 studies, 287 participants; low-certainty evidence) and of the lower limb (SMD 0.71, 95% CI 0.15 to 1.28; P = 0.01; 1 study, 51 participants; very low-certainty evidence). There were no intervention-related SAEs. More time in rehabilitation did not affect the risk of SAEs/death (RR 1.20, 95% CI 0.51 to 2.85; P = 0.68; I2 = 0%; 2 studies, 379 participants; low-certainty evidence), but few studies measured these outcomes. Predefined subgroup analyses comparing studies with a larger difference of total time spent in rehabilitation between intervention groups to studies with a smaller difference found greater improvements for studies with a larger difference. This was statistically significant for ADL outcomes (P = 0.02) and activity measures of the upper limb (P = 0.04), but not for activity measures of the lower limb (P = 0.41) or motor impairment measures of the upper limb (P = 0.06).

AUTHORS' CONCLUSIONS

An increase in time spent in the same type of rehabilitation after stroke results in little to no difference in meaningful activities such as activities of daily living and activities of the upper and lower limb but a small benefit in measures of motor impairment (low- to very low-certainty evidence for all findings). If the increase in time spent in rehabilitation exceeds a threshold, this may lead to improved outcomes. There is currently insufficient evidence to recommend a minimum beneficial daily amount in clinical practice. The findings of this study are limited by a lack of studies with a significant contrast in amount of additional rehabilitation provided between control and intervention groups. Large, well-designed, high-quality RCTs that measure time spent in all rehabilitation activities (not just interventional) and provide a large contrast (minimum of 1000 minutes) in amount of rehabilitation between groups would provide further evidence for effect of time spent in rehabilitation.