Post-stroke Cognition is Associated with Stroke Survivor Quality of Life and Caregiver Outcomes: A Systematic Review and Meta-analysis

Disability arising from post-stroke cognitive impairment is a likely contributor to the poor quality of life (QoL) stroke survivors and their carers frequently experience, but this has not been summarily quantified. A systematic literature review and meta-analysis was completed examining the association between general and domain-specific post-stroke cognitive functioning and adult stroke survivor QoL, caregiver QoL, and caregiver burden. Five databases were systematically searched, and eligibility for inclusion, data extraction, and study quality were evaluated by two reviewers using a standardised protocol. Effects sizes (r) were estimated using a random effects model. Thirty-eight studies were identified, generating a sample of 7365 stroke survivors (median age 63.02 years, range 25-93) followed for 3 to 132 months post-stroke. Overall cognition (all domains combined) demonstrated a significant small to medium association with QoL, r = 0.23 (95% CI 0.18-0.28), p < 0.001. The cognitive domains of speed, attention, visuospatial, memory, and executive skills, but not language, also demonstrated a significant relationship with QoL. Regarding caregiver outcomes, 15 studies were identified resulting in a sample of 2421 caregivers (median age 58.12 years, range 18-82) followed for 3 to 84 months post-stroke. Stroke survivor overall cognitive ability again demonstrated a significant small to medium association with caregiver outcomes (QoL and burden combined), r = 0.17 (95% CI 0.10-0.24), p < 0.001. In conclusion, lower post-stroke cognitive performance is associated with significant reductions in stroke survivor QoL and poorer caregiver outcomes. Cognitive assessment is recommended early to identify those at risk and implement timely interventions to support both stroke survivors and their caregivers.

Quality of life of stroke survivors in Africa: a systematic review and meta-analysis

PURPOSE

Functional impairments and socioeconomic constraints associated with stroke affect quality of life (QoL). With limited care and social support resources, there is a greater anticipated decline in QoL among stroke survivors in Africa. This study aims to examine post-stroke QoL, properties of outcome measures adopted and predictors of the QoL among African stroke survivors.

METHODS

African Journals Online, CINAHL, PsychINFO, PubMed and Web of Science databases were searched from inception to February 2020. Methodological quality was assessed using the Agency for Healthcare Research and Quality (ARHQ) methodology checklist for observational studies.

RESULTS

Twenty-eight studies recruiting 2572 (76.4%) stroke survivors and 795 (23.6%) healthy volunteers were included. Studies were conducted in eight African countries between 2007 and 2019. Methodological quality of studies was good. Overall, stroke survivors reported a low QoL. Six studies comparing QoL between stroke survivors and healthy controls were pooled for meta-analysis. Results showed a biased-adjusted standardised mean difference (Hedges's g) of 1.13 (95% CI 0.71 to 1.56; p < 0.001), indicating better QoL among healthy controls. Only 4 (14.3%) studies used translated or cross-culturally adapted QoL assessment tools. The most commonly reported predictor of QoL was post-stroke disability (35.8% of studies) which is followed by depression (28.6%) and stroke severity (28.6%).

CONCLUSIONS

Overall, African stroke survivors reported comparatively lower QoL as compared to age-matched healthy controls. This highlights the need for cross-culturally validated assessment tools and more robust post-stroke QoL evaluation across the African continent. To improve QoL of stroke survivors in Africa, early interventions should focus on reducing disability and depression associated with stroke. PROSPERO registration number: CRD42019137653.

Quantitative Assessment of Upper Limb Motor Function in Ethiopian Acquired Brain Injured Patients Using a Low-Cost Wearable Sensor

Acquired brain injuries place a significant burden on sub-Saharan African rehabilitation clinicians and health care facilities. While wearable sensors have the potential to alleviate these issues, many are beyond the financial capabilities of the majority of African persons and clinics. To bridge this gap, we have developed a low-cost wrist-worn sensor (the outREACH sensor) capable of accurately measuring upper limb movement kinematics. In this study we evaluated the extent to which the outREACH sensor is sensitive to the hand performing the task (unimpaired, impaired) and level of impairment (mild, moderate) in 14 Ethiopian persons with acquired brain injury (mean age = 51.6 ± 12.2 years, 1 female, 13 male). Participants performed an object manipulation task with both the impaired and the unimpaired limb, and reaching performance was measured using standard kinematic measures (i.e., movement time, spectral arc length, peak velocity, peak acceleration, mean velocity, mean acceleration). Overall, movements were smoother and faster when performed by the patient's unimpaired limb. In contrast, maximum velocity did not differ between the two limbs. Moreover, the outREACH sensor was sensitive to differences in performance-based upper limb impairment. Fugl-Meyer assessment for upper extremity scores were significantly correlated with movement time, spectral arc length, and peak velocity. Upper limb movement kinematics can be accurately measured using the outREACH sensor. The outREACH sensor can be a valuable addition to standardized clinical measures that provides rehabilitation clinicians with information regarding initial upper limb impairment level and changes in function across the rehabilitation lifespan.

Development of a Post-stroke Upper Limb Rehabilitation Wearable Sensor for Use in Sub-Saharan Africa: A Pilot Validation Study

The development of context-appropriate sensor technologies could alleviate the significant burden of stroke in Sub-Saharan African rehabilitation clinicians and health care facilities. However, many commercially available wearable sensors are beyond the financial capabilities of the majority of African persons. In this study, we evaluated the concurrent validity of a low-cost wearable sensor (i.e., the outREACH sensor) to measure upper limb movement kinematics of 31 healthy persons, using an 8-camera Vicon motion capture system as the reference standard. The outREACH sensor showed high correlation (r range: 0.808-0.990) and agreement (mean difference range: -1.60 to 1.10) with the reference system regardless of task or kinematic parameter. Moreover, Bland-Altman analyses indicated that there were no significant systematic errors present. This study indicates that upper limb movement kinematics can be accurately measured using the outREACH sensor, and have the potential to enhance stroke evaluation and rehabilitation in sub-Saharan Africa.

Developing an mHealth app for post-stroke upper limb rehabilitation: Feedback from US and Ethiopian rehabilitation clinicians

Stroke is the leading cause of adult disability worldwide, with 70 percent of survivors exhibiting residual impairments of the upper limb that require frequent in-person visits to rehabilitation clinic over several months. This study explored rehabilitation clinician's preferences for design features to be included in an mHealth-enabled app for post-stroke upper limb rehabilitation. Data were collected via online survey, sampling participants from Ethiopia (n = 69) and the United States (n = 75). Survey results indicated that Ethiopian and US rehabilitation clinicians have different opinions about the importance of design features that should be included in a stroke tele-rehabilitation system which are likely due to differences in culture, the availability of human and physical resources, and how the field of rehabilitation is organized and managed. Our results, thus, indicate that mHealth technologies must be tailored to the geographical and cultural context of the end users.

Efficacy of cognitive behavior language therapy for aphasia following stroke: Implications for language education research

BACKGROUND/OBJECTIVE

Evidence from previous research has shown that the incidence of aphasia following a stroke is high in Nigeria and other countries, and there is a call for intervention programs. The objective of the current study was to investigate the efficacy of cognitive behavior language therapy (CBLT) on aphasia following a stroke.

METHODS

The study was designed as a group randomized trial, which involved treatment and no-treatment control procedures. The participants of the study were 86 patients who had experienced aphasia following a stroke. The Porch Index of Communicative Ability (PICA) and Speech-Language Unhelpful Thoughts and Beliefs Scale (SLUTBS) were the measures used in the study. The repeated measures analysis of variance procedure, with Partial eta squared (Equation is included in full-text article.), adjusted R, mean, standard deviation, and upper/lower limit was followed in analyzing the data collected in the study.

RESULTS

The CBLT intervention significantly reduced aphasia following a stroke and significantly reduced speech-language and unhelpful thought and beliefs among aphasic stroke patients exposed to the treatment intervention when compared with the no-treatment control group.

CONCLUSION

Based on the findings of the study, language educators, speech and language pathologists and therapists in education institutions, hospitals, and rehabilitation centers should adopt the principles of CBLT used in the current study to help them improve communication ability among aphasia stroke patients.

Stroke in the 21st Century: A Snapshot of the Burden, Epidemiology, and Quality of Life

Stroke is ranked as the second leading cause of death worldwide with an annual mortality rate of about 5.5 million. Not only does the burden of stroke lie in the high mortality but the high morbidity also results in up to 50% of survivors being chronically disabled. Thus stroke is a disease of immense public health importance with serious economic and social consequences. The public health burden of stroke is set to rise over future decades because of demographic transitions of populations, particularly in developing countries. This paper provides an overview of stroke in the 21^st century from a public health perspective.

Understanding the cultural meanings of stroke in the Ghanaian setting: A qualitative study exploring the perspectives of local community residents

Background: Stroke has undergone different medical constructions over the years. While the medical profession posits that disease is a biological condition, universal and unchanging, social constructionists perceive illness as the social meaning of the biological condition. Even though the medical notion of stroke is monolithic and sometimes contradicts the representations by local community residents, little attention has been paid to understanding the cultural meanings of stroke. This study explores the cultural meanings of stroke in five different cultural settings across Ghana. Methods: 30 focus group discussions (FGDs) were conducted with local community members in five communities (Ga Mashie, Tafo, Gyegyeano, Chanshegu and Agorve) located in five regions in Ghana. The FGDs were conducted in Ga, Twi, Fante, Ewe and Dagbani, and were transcribed verbatim into English. The transcripts were analysed thematically. Results: The local words used for stroke in all the five cultural settings focused on physical disability associated with stroke after its onset, and this formed the dominant source of fear about the condition. Participants mentioned that spiritual and left-side stroke have the most debilitating impact on the sufferer. Although there was a general consensus that anyone can be at risk of stroke, there was a gender dynamics in the explanation of risk relativity. Participants believed that stroke can be cured through early detection and treatment, use of herbal medicines, and availability of financial resources. Compared to other disabling conditions, the community residents perceived stroke to be more severe due to the multifaceted disabilities associated with the condition. Conclusions: This study showed that the social meanings of stroke in the five communities are multifaceted, and reflected co-existence of biomedical and cultural frameworks.  The findings showed the need to pay good attention to the sociocultural context when developing interventions strategies on stroke prevention and control in Ghana.

Prevalence of Balance Impairment Among Stroke Survivors Undergoing Neurorehabilitation in Nigeria

BACKGROUND

Poststroke balance impairment adversely affects stroke outcomes and addressing the impairment is expected to constitute an important focus of neurorehabilitation.

AIMS

To examine the prevalence and factors associated with balance impairment after stroke.

METHODS

Ninety-five stroke survivors undergoing neurorehabilitation at 2 government hospitals in Northern Nigeria participated in this cross-sectional study. Berg Balance Scale (BBS) was used to assess the presence of balance impairment (BBS score of 0-20). Prevalence of balance impairment was presented as frequency and percentage while demographic and stroke-related determinants of balance impairments were identified using logistic regression analysis.

RESULTS

Thirty-five (36.8%) stroke survivors had balance impairment, and age, gender, and poststroke duration were statistically significant determinants. Stroke survivors aged less than 40 years (odds ratio [OR] = .14 [confidence interval [CI] = .20-.94]) and 40-59 years (OR = .23 [CI = .06-.81]) had a lower likelihood of having balance impairment compared to stroke survivors aged 60 years and above. Similarly, males had a lower likelihood of having balance impairment (OR = 1.60 [CI = .05-.55]) compared to females while those in the acute/subacute phase of stroke had a 7-fold likelihood of having balance impairment (OR = 7.74 [CI = 2.63-22.79]) compared to those with chronic stroke.

CONCLUSIONS

Poststroke balance impairment appears to be significantly influenced by stroke survivors' age, gender, and poststroke duration. Hence, these variables should be considered when planning rehabilitation strategies for improving balance after stroke.

Understanding the cultural meanings of stroke in the Ghanaian setting: A qualitative study exploring the perspectives of local community residents

Background: Stroke has undergone different medical constructions over the years. While the medical profession posits that disease is a biological condition, universal and unchanging, social constructionists perceive illness as the social meaning of the biological condition. Even though the medical notion of stroke is monolithic and sometimes contradicts the representations by local community residents, little attention has been paid to understanding the cultural meanings of stroke. This study explores the cultural meanings of stroke in five different cultural settings in Ghana. Methods: 30 focus group discussions (FGDs) were conducted with local community members in five communities (Ga Mashie, Tafo, Gyegyeano, Chanshegu and Agorve) located in five regions in Ghana. The FGDs were conducted in Ga, Twi, Fante, Ewe and Dagbani, and were transcribed verbatim into English. The transcripts were analysed thematically. Results: The local words used for stroke in all the five cultural settings focused on physical disability associated with stroke after its onset, and this formed the dominant source of fear about the condition. Participants mentioned that spiritual and left-side stroke have the most debilitating impact on the sufferer. Although there was a general consensus that anyone can be at risk of stroke, there was a gender dynamics in the explanation of risk relativity. Participants believed that stroke can be cured through early detection and treatment, use of herbal medicines, and availability of financial resources. Compared to other disabling conditions, the community residents perceived stroke to be more severe due to its multifaceted disabilities. Conclusions: This study showed that the social meanings of stroke in the five communities are multifaceted, and reflected co-existence of biomedical and cultural frameworks.  The findings showed the need to pay good attention to the sociocultural context when developing interventions strategies on stroke prevention and control.

Plasma Glial Fibrillary Acidic Protein, Copeptin, and Matrix Metalloproteinase-9 Concentrations among West African Stroke Subjects Compared with Stroke-Free Controls

BACKGROUND

Measurement of plasma molecular markers among stroke patients has been proposed as an avenue for improving the accuracy of stroke diagnosis. There is paucity of data on the potential role of these markers in resource-limited settings, where the burden of stroke is greatest.

OBJECTIVE

To assess the potential diagnostic and prognostic performance of 3 proposed biomarkers for stroke in a resource-constrained setting.

METHODS

Consecutive stroke subjects presenting at a tertiary medical center in Kumasi, Ghana, with radiologically confirmed diagnosis and etiologic subtype information available were recruited along with age- and gender-matched controls in a 2:1 ratio. Plasma concentrations of glial fibrillary acidic protein (GFAP), copeptin, and matrix metalloproteinase-9 (MMP-9) among stroke patients and stroke-free controls were measured in duplicates using enzyme linked immunoassays. Diagnostic and prognostic correlates were assessed using area-under-the-curve (AUC) measures of receiver operator curves and logistic regression analysis, respectively.

RESULTS

There were 156 stroke subjects with a mean age of 61.3 years of which 47.4% were females and 74 age- and gender-matched stroke-free controls. Median (interquartile range) time from symptom onset to hospital presentation for care was 7 days (5-11). Diagnostic accuracy of a single measurement of the 3 biomarkers for stroke using AUC (95% confidence interval) plots were as follows: .84 (.77-0.91), P < .0001, for GFAP; .85 (.79-0.92), P < .0001, for copeptin; and .65 (.56-0.73), P = .0003, for MMP-9. None of the biomarkers was associated with stroke severity or mortality.

CONCLUSION

Plasma concentrations of GFAP and copeptin demonstrated stronger associations with stroke occurrence in this West African cohort compared with controls.

Interrelationship between the general characteristics of Korean stroke patients and the variables of the sexual functions: random forest and boosting algorithm

[Purpose] The purpose of this study is to examine patient preferences for counseling related to sexuality post-stroke in Korea. [Subjects and Methods] A survey was conducted on 200 stroke patients. Among the 200 submitted questionnaires, 156 responded but 147 cases are available. The questionnaire is composed of 27 questions such as 8 independent variables related to the general characteristics of the patients, 7 dependent variables in conjunction with sexual intercourse and changed muscle tone, 6 questions regarding to changed sexual function, and 6 questions about a changed motor and a sensory function after stroke. To analyze the factors related to a sexual function after a stroke, we used the random forest, boosting algorithm and MANOVA. [Results] The most important variable in variable group 1 is VAR1, and then VAR22, VAR23, VAR26, VAR27, VAR25, VAR21 and VAR 24 respectively. The most important variable in variable group 2 is VAR22, and then VAR26, VAR23, VAR25, VAR1, VAR27, VAR21 and VAR 24. Finally, for variable group 3, VAR1 has the most important percentage, and we have the order as VAR26, VAR23, VAR27, VAR22, VAR25, VAR21 and VAR 24 among the rest of variables. The result of variable importance in boosting algorithm is somehow the same as that of random forest. [Conclusion] As a result of our analysis, we figured out that duration of illness, age, and education level are important factors of sexual functions for Korean Stroke patients.

Stroke minimization through additive anti-atherosclerotic agents in routine treatment (SMAART): A pilot trial concept for improving stroke outcomes in sub-Saharan Africa

There has been an unprecedented rise in the prevalence of stroke in sub-Saharan Africa (SSA), which when compared to stroke profiles in high-income countries (HIC) is characterized by a younger age of onset, higher case fatality rates, and more severe disability among survivors. Stroke survivors in SSA (vs. HIC) are especially at high risk for recurrent vascular events or death due to undiagnosed or under-controlled vascular risk factors, logistical challenges, low health literacy, and lack of care affordability. While international expert consensus secondary prevention guidelines recommend that antihypertensive, statin and anti-platelet therapy, be initiated promptly after ischemic stroke and adhered to in a persistent fashion to achieve optimal vascular risk reduction, these goals are seldom realized in routine clinical care settings in SSA. A relatively simple, low-cost, evidence-based strategy that could be largely applied in a uniform manner to stroke survivors in low-to-middle income countries (LMICs), including the nations of SSA, is sorely needed. Fixed-dose combination pills, also known "polypills", containing generic drugs, i.e. Aspirin, a statin, and blood pressure (BP) lowering medication(s) may be a viable avenue to improve medication adherence and consequently reduce risk of further disability or death on a large scale among stroke survivors encountered in resource-constrained regions. In this conceptual article, we review the data supporting the rationale for a polypill to improve stroke outcomes in SSA and propose the conduct of a Stroke Minimization through Additive Anti-atherosclerotic Agent in Routine Treatment (SMAART) pilot study to determine the impact of a polypill such as the Polycap DS® in reducing future vascular risk compared to usual care in recent stroke in SSA. A preliminarily feasible and efficacy-suggesting SMAART trial could inform the future design of a multi-center, double-blinded, placebo-controlled, randomized trial comparing the clinical efficacy of the polypill strategy for vascular risk moderation among stroke survivors in LMICs.

Community reintegration and related factors in a Nigerian stroke sample

BACKGROUND

The goal of stroke rehabilitation has shifted from mere survival of a victim to how well a survivor can be effectively reintegrated back into the community.

OBJECTIVES

The present study determined the level of satisfaction with community reintegration (CR) and related factors among Nigerian community-dwelling stroke survivors (CDSS).

METHODS

This was a cross-sectional survey of 71 volunteering CDSS (35 males, 36 females) from selected South-Eastern Nigerian communities. Reintegration to Normal Living Index was used to assess participants' CR. Data was analysed using Spearman rank-order correlation, Kruskal-Wallis and Mann-Whitney U tests at p≤0.05.

RESULTS

Participants generally had deficits in CR which was either mild/moderate (52.1%) or severe (47.9%). Scores in the CR domains of distance mobility, performance of daily activities, recreational activities and family roles were particularly low (median scores ≤ 4). CR was significantly correlated with and influenced by age (r=-0.35; p=0.00) and presence/absence of diabetes mellitus (u=3.56.50; p=0.01), pre- (k=6.13; p=0.05) and post-stroke employment (k=18.26; p=0.00) status, type of assistive mobility device being used (AMD) (k=25.39; p=0.00) and support from the community (k=7.15; p=0.03) respectively.

CONCLUSION

CR was generally poor for this CDSS sample. Survivors who are older, having diabetes as co-morbidity, using AMD (particularly wheel-chair) and without employment pre- and/or post-stroke may require keener attention. Rehabilitation focus may be targeted at enhancing mobility functions, vocational and social skills.

Quality of life and associated factors among poststroke clinic attendees at a University Teaching Hospital in Nigeria

BACKGROUND

Quality of life (QOL) measures are effective in quantifying disease burden after stroke, more so than levels of debility. The objective of this study is to determine QOL and associated factors of stroke survivors in Lagos, Nigeria.

MATERIALS AND METHODS

Seventy stroke survivors (study sample) and seventy stable hypertensive patients (control sample) attending clinics at a Nigerian hospital were recruited for the study. Respondents were assessed using sociodemographic/clinical questionnaires, modified mini-mental state examination, modified Rankin Scale, schedule for clinical assessment in neuropsychiatry, and World Health Organization-QOL-BREF.

RESULTS

Mean ages of the study and control respondents were 57.43 (±9.67) years and 57.33 (±9.33) years, respectively. Each sample comprised 38 male and 32 female respondents. Stroke survivors were significantly more likely to: be unemployed (P = 0.001), pay more for healthcare (P = 0.001), consume alcohol (P = 0.02), and have physical impairments (P = 0.001) compared with control. The mean QOL scores of stroke survivors were significantly lower than controls across all spheres. Stroke survivors who were unemployed, younger, female, paying more for healthcare, more disabled, with right stroke lateralization, having comorbidities, and sexual dysfunction had significantly poorer QOL specific grades. Depression or anxiety poststroke was also associated with reduced QOL means scores.

CONCLUSION

Besides, clinical variables such as levels of disability and stroke lesion lateralization, other factors such as unemployment, health costs, age, gender, and emotional problems influenced QOL after stroke.

Phenotyping Stroke in Sub-Saharan Africa: Stroke Investigative Research and Education Network (SIREN) Phenomics Protocol

BACKGROUND

As the second leading cause of death and the leading cause of adult-onset disability, stroke is a major public health concern particularly pertinent in Sub-Saharan Africa (SSA), where nearly 80% of all global stroke mortalities occur, and stroke burden is projected to increase in the coming decades. However, traditional and emerging risk factors for stroke in SSA have not been well characterized, thus limiting efforts at curbing its devastating toll. The Stroke Investigative Research and Education Network (SIREN) project is aimed at comprehensively evaluating the key environmental and genomic risk factors for stroke (and its subtypes) in SSA while simultaneously building capacities in phenomics, biobanking, genomics, biostatistics, and bioinformatics for brain research.

METHODS

SIREN is a transnational, multicentre, hospital and community-based study involving 3,000 cases and 3,000 controls recruited from 8 sites in Ghana and Nigeria. Cases will be hospital-based patients with first stroke within 10 days of onset in whom neurovascular imaging will be performed. Etiological and topographical stroke subtypes will be documented for all cases. Controls will be hospital- and community-based participants, matched to cases on the basis of gender, ethnicity, and age (±5 years). Information will be collected on known and proposed emerging risk factors for stroke. STUDY SIGNIFICANCE: SIREN is the largest study of stroke in Africa to date. It is anticipated that it will shed light on the phenotypic characteristics and risk factors of stroke and ultimately provide evidence base for strategic interventions to curtail the burgeoning burden of stroke on the sub-continent.

Trends in stroke admission and mortality rates from 1983 to 2013 in central Ghana

BACKGROUND

Accumulating data based on model-derived estimates suggest rising rates of stroke in sub-Saharan Africa over the next several decades. Stroke is a leading cause of death, disability, and dementia worldwide. Directly enumerated hospital-based data on the longitudinal trajectory of stroke admissions and deaths in sub-Saharan Africa could help hospital administrators, public health officials, and government policy-makers with planning and utilization of scarce resources.

OBJECTIVE

To evaluate 30-year trends in stroke admission and mortality rates in central Ghana.

METHODS

We undertook a retrospective analysis of data on stroke admissions and mortality at a tertiary referral hospital in central Ghana between 1983 and 2013. Rates of stroke admissions and mortality were expressed as stroke admissions or deaths divided by total number of hospital admissions or deaths respectively. Yearly crude case fatality from stroke was calculated and predictors of stroke mortality were determined using Cox proportional hazards regression analysis.

RESULTS

Over the period, there were 12,233 stroke admissions with equal gender distribution. The rate of stroke admissions increased progressively from 5.32/1000 admissions in 1983 to 13.85/1000 admissions in 2010 corresponding to a 260% rise over the period. Stroke mortality rates also increased from 3.40/1000 deaths to 6.66/1000 deaths over the 30-year period. The average 28-day mortality over the period was 41.1%. Predictors of in-patient mortality were increasing age-aHR of 1.31 (1.16-1.47) for age>80years compared with <40years and admissions in 2000's compared with 1980's; aHR of 1.32 (1.26-1.39). Of the 1132 stroke patients with neuroimaging data: 569 (50.3%) had intracerebral hemorrhage, 382 (33.7%) had ischemic stroke and 181 (16.0) had sub-arachnoid hemorrhage. Patients with ischemic stroke were significantly older than those with ICH and SAH respectively.

CONCLUSION

Rates of stroke admission and mortality have increased steadily over the past three decades in central Ghana. More intensive risk modification and optimization of acute stroke care are urgently needed to stem these worrisome trends.

Profile and health-related quality of life of Ghanaian stroke survivors

BACKGROUND

Stroke is a leading cause of mortality with a major effect on health-related quality of life (HRQoL). There are no previous studies exploring HRQoL among stroke survivors in Ghana, despite the increasing public health significance of the disease in this country. Here we describe the profile of and factors associated with HRQoL among stroke survivors in Ghana.

METHODS

This was a cross-sectional study involving 156 stroke survivors and 156 age- and sex-matched, apparently healthy controls. A robust HRQoL questionnaire involving seven domains was used to collect data from the study participants. Clinical epidemiology data were also collected from stroke survivors on parameters such as stroke severity and risk factors. Statistical analyses were performed on the interrelationships among the study variables.

RESULTS

The mean ages of the stroke survivors and healthy controls were 58.0 (standard deviation, 11.4) and 57.6 (standard deviation, 12.0) years, respectively. Fifty-three percent (86) of the stroke survivors had mild stroke and 35.3% (55) had moderate stroke, whereas 12.2% (19) had severe stroke. Ischemic infarction was the prevalent stroke subtype (78.1%). Hypertension was the most common risk factor (89%) among the stroke survivors, followed by diabetes (29%). HRQoL scores ranged from 57.7% (cognitive domain) to 80.0% (spirit domain) for stroke survivors, whereas HRQoL scores of the control group ranged from 65.6% (cognitive domain) to 85.2% (soul domain). For each HRQoL domain, significantly higher scores were observed for the control group compared with the stroke survivors, at P<0.05. Determinants of HRQoL of stroke survivors in multivariate analysis included age, stroke severity, poststroke duration, stroke recurrence, frequency of laughter, and negative emotions.

CONCLUSION

The most affected HRQoL domains are of the physical, psychoemotional, and cognitive domains. Rehabilitation of stroke patients in this region should include interventions targeted at these domains and modifying the statistical determinants of HRQoL where possible.

Impact of poststroke fatigue on health-related quality of life of nigerian stroke survivors

BACKGROUND AND PURPOSE

A stroke event is often characterized by a number of debilitating consequences that may impact negatively on the health-related quality of life (HRQL) of survivors. This study examined the impact of poststroke fatigue (PSF), a persistent and prevalent stroke consequence, on HRQL of Nigerian stroke survivors.

METHODS

One hundred stroke survivors were recruited from the physiotherapy outpatient departments of two tertiary hospitals in Northern Nigeria. The Fatigue Severity Scale and Health-Related Quality of Life in Stroke Patients-26 were respectively used to assess PSF and HRQL. The independent impact of PSF on overall and domain-specific HRQL was examined using hierarchical regression analyses.

RESULTS

Mean age of the stroke survivors was 55.32 years (SD 13.9 years). The majority were males (66%), had suffered ischemic stroke (70%) and presented with moderately severe disability (42%). After controlling for demographic and stroke-related variables, PSF was found to be significantly and independently associated with all the domains of HRQL albeit at varying degrees. While the influence of PSF on the emotional domain was the most pronounced and uniquely contributed to 15% of the variance in the domain, its influence on the cognitive domain was the least prominent. PSF also solely accounted for 9% of the variation in overall HRQL with higher levels of PSF related with lower HRQL.

CONCLUSIONS

Being a potentially treatable condition, PSF's significant impact on HRQL has implications for successful stroke care and rehabilitation. For instance, addressing PSF through appropriate interventions may assist in enhancing HRQL of stroke survivors.

Profile and determinants of vascular cognitive impairment in African stroke survivors: the CogFAST Nigeria Study

OBJECTIVE

Sub-Saharan Africa faces a potential epidemic of non-communicable diseases including stroke and dementia but little is known about the burden of stroke-related cognitive dysfunction. We assessed the baseline profile and factors associated with vascular cognitive impairment (VCI) in stroke survivors participating in the Cognitive Function After STroke (CogFAST) Nigeria Study.

METHODS

We recruited 217 subjects (>45 years old) comprising 143 stroke survivors and 74 demographically matched stroke-free healthy controls. We obtained demographic, clinical and lifestyle information and assessed the cognitive status of the subjects at baseline three months after stroke. Standard neuropsychological tests included the Vascular Neuropsychological Battery, which assessed executive function/mental speed, memory, language, and visuospatial/visuoconstructive functioning. Cognitive impairment and dementia were defined based on the AHA/ASA VCI guidelines and the DSM IV criteria.

RESULTS

Among the stroke survivors (mean ag e= 60.4+9.5 years, 43.4% female, mean number of years of education = 9.4+5.6 years, median modified Rankin score = 2), 57 (39.9%) had cognitive impairment no dementia while 12 (8.4%) were demented at baseline. Multivariate analysis revealed that older age [OR = 1.05 (1.00-1.09)], low education [OR = 5.09 (2.17-11.95)], pre-stroke cognitive decline [OR = 4.51 (1.20-16.88)] and medial temporal lobe atrophy [OR = 2.25 (1.16-4.35)] were independently associated with cognitive dysfunction whereas pre-stroke daily intake of fish [p = 0.022, OR = 0.39 (0.15-0.89)] was inversely associated.

CONCLUSIONS

These results suggest a high frequency of early VCI in older Nigerian stroke survivors. Apart from aging, associated neurodegeneration and cognitive decline, educational level and pre-stroke diet particularly fish consumption were identified as modifiable factors. This emphasizes the vital role of education and healthy nutrition in building reserves to ameliorate cognitive dysfunction after stroke.

Predictors of poststroke health-related quality of life in Nigerian stroke survivors: a 1-year follow-up study

This study aims to identify the predictors in the different aspects of the health-related quality of life (HRQoL) and to measure the changes of functional status over time in a cohort of Nigerian stroke survivors. A prospective observational study was conducted in three hospitals of Kano state of Nigeria where stroke survivors receive rehabilitation. The linguistic-validated Hausa versions of the stroke impact scale 3.0, modified Rankin scale, Barthel index and Beck depression inventory scales were used. Paired samples t-test was used to calculate the amount of changes that occur over time and the forward stepwise linear regression model was used to identify the predictors. A total of 233 stroke survivors were surveyed at 6 months, and 93% (217/233) were followed at 1 year after stroke. Functional disabilities were significantly reduced during the recovery phase. Motor impairment, disability, and level of depression were independent predictors of HRQoL in the multivariate regression analysis. The involvement of family members as caregivers is the key factor for those survivors with improved functional status. Thus, to enhance the quality of poststroke life, it is proposed that a holistic stroke rehabilitation service and an active involvement of family members are established at every possible level.

Gait and balance performance of stroke survivors in South-Western Nigeria--a cross-sectional study

INTRODUCTION

Stroke survivors are often left with neurological and functional deficits, which impair their ability to walk and affect their balance. This study assessed gait parameters and balance performance among stroke survivors and examined the relationship between these two factors.

METHODS

Seventy stroke survivors (65.7% males) who were 6 months or more post stroke participated in this study. Using Observational Gait Analysis, the gait of participants was assessed by gait speed and cadence. Balance performance was assessed using the Activities-specific Balance Confidence scale for balance self-efficacy and Functional Reach Test for standing balance.

RESULTS

Participants had a mean age of 53.5 ± 10.4 years. Forty five (64.3%) stroke survivors had haemorrhagic stroke while 25 (35.7%) had ischaemic stroke. The mean gait speed and cadence were 0.6 ± 0.3m/s and 69.1 ± 38.1 steps/min, respectively. The mean balance self-efficacy score was 66.5 ± 17.7 and mean functional reach distance was 18.7 ± 2.6 cm. There were significant relationships between gait speed and balance self-efficacy (r =0.461, p =0.001) and between cadence and functional reach distance (r =0.247, p =0.020).

CONCLUSION

This study concluded that stroke survivors with higher cadences had higher functional reach distances, and those with higher gait speeds had better balance self-efficacy. Gait speed and cadence are factors related to balance performance. These factors should be considered during gait and balance retraining and should go pariparsu in the rehabilitation of stroke survivors.

Development and evaluation of the Primary Healthcare-based Physiotherapy Intervention and its effects on selected indices of stroke recovery

Aim:

To develop a Primary Healthcare-Based Physiotherapy Intervention (PHCPI) that requires simple, inexpensive, easy-to-use equipment for stroke rehabilitation and evaluate its effects on selected clinical indices of recovery among post-acute stroke survivors over a 10-week period.

Methods:

Three databases (Medline, Pubmed and PEDro) were used to identify treatment approaches with proven efficacy. The authors synthesised these treatment approaches to develop the PHCPI, which was used in a repeated measure design involving 25 (mean age=60.6 ± 10.2 years) consenting individuals with first-incidence stroke. These individuals were treated at a primary health centre, twice weekly for 10 consecutive weeks. Outcomes were assessed using the Modified Motor Assessment Scale (MMAS), the Short Form Postural Assessment Scale for Stroke (SF-PASS) and the Reintegration to Normal Living Index (RNLI), before the intervention and fortnightly thereafter. Walking speed and quality of life were also assessed before the intervention and at week 10 of it.

Results:

Within-subject multivariate analysis, after controlling for gender, showed a significant increase in motor function, postural balance, walking speed and quality of life. Their community reintegration scores also improved over the period.

Conclusion:

The PHCPI resulted in improved motor function, community reintegration, walking speed, postural balance and quality of life among community-dwelling stroke survivors. This intervention can be used for stroke rehabilitation at primary health centres.

HRQOLISP-26: A Concise, Multiculturally Valid, Multidimensional, Flexible, and Reliable Stroke-Specific Measure

Background. A multidimensional, brief, and flexible stroke-specific health-related quality of life (HRQOL) measure is still needed. The aim was to develop a shortened version of the HRQOLISP-102, a multiculturally generated measure with excellent psychometric properties. Methods. Participants included 100 (Ibadan, Nigeria) and 103 (Berlin, Germany) stroke patients compared to 100 (Ibadan) and 50 (Berlin) apparently healthy adults. Using standard protocol, the 26-item version was generated, consisting of therapeutically relevant physical, psychological, cognitive, and ecosocial domains. Criterion validity of the HRQOLISP-26 was determined using Bland-Altman statistics. "Known groups" validity was assessed using NIHSS, stroke levity score, and modified Rankin scale. Results. HRQOLISP-26 was easily interpretable and precise with no significant floor/ceiling effect. It can be completed within 7 minutes. It showed good content, construct, "known groups," and criterion validity. It demonstrated good internal consistency (α = 0.81, 0.89) and test-retest reliability. Conclusions. HRQOLISP-26 is novel, brief, multiculturally-valid, and flexible for routine assessment of HRQOL in stroke patients.

Impact of stroke on health-related quality of life in diverse cultures: the Berlin-Ibadan multicenter international study

Background

Various studies have reported discordant profiles of health-related quality of life (HRQOL) after stroke. The aims of this study, the first of its kind, were to determine the real impact of stroke on HRQOL across diverse cultures; and to compare HRQOL between stroke patients and healthy adults, and across stroke severity strata.

Methods

100 stroke patients and 100 apparently healthy adults (AHAs) in Nigeria; as well as 103 stroke and 50 AHAs in Germany participated. Stroke severity was measured using the National Institute of Health Stroke Scale, Stroke Levity Scale and modified Rankin scale. HRQOL was evaluated using the HRQOL In Stroke Patients (HRQOLISP) measure, a holistic multiculturally-validated measure with seven therapeutically-relevant domains distributed into two spheres.

Results

Domains within the spiritual sphere were considered more important by stroke patients. In both countries, stroke patients significantly (0.00001 < p < 0.004) had worse HRQOL than AHAs in all domains within the physical sphere. This was not so for the spiritual sphere. Consistently, stroke severity correlated significantly with all domains in the physical sphere unlike the spiritual sphere. In diverse cultures, the correlation coefficients between HRQOL and all indices of stroke severity revealed a decremental trend from the physical domain (rho = 0.77, p < 0.00001) to the spiritual domain (rho = 0.01, p = 0.893).

Conclusions

Consistently, stroke elicited a decremental response across domains, with domains in the spiritual sphere being relatively stroke-resilient. The potential utility of the relatively preserved spiritual sphere in facilitating stroke rehabilitation requires evaluation in diverse cultures.

Quality of life and its correlates in caregivers of stroke survivors from a Nigerian population

PURPOSE

The study aimed at determining the quality of life (QOL) of caregivers of stroke survivors in a Nigeria population and some patient and caregiver-related variables that may be associated with it.

METHOD

A survey of the QOL of volunteering informal caregivers of stroke survivors in purposively selected tertiary health centres from South-Eastern Nigeria was done using the SF-12 questionnaire.

RESULT

Caregivers rated their QOL fairly well. Older age, female gender and closeness in relationship to survivor were caregivers' variables that were significantly related to poorer QOL scores. Being a woman close relative is associated with lower mental health scores while being an older close relative contributed to lower physical health score (P < 0.05). Caregivers' scores on the physical and mental health domains correlated moderately with each other (r = 0.52) and highly with their overall QOL scores (r = 0.81 and 0.88).

CONCLUSION

Caring for stroke survivors in Nigeria seems to have adverse effects on the QOL of closer relatives who are either women or older. There is a need for clinicians to help those caregivers at risk find ways of improving and optimizing their QOL.

Psychometric properties of the HRQOLISP-40: a novel, shortened multiculturally valid holistic stroke measure

BACKGROUND

A recent review showed that no existing instrument measured the entire spectrum of health-related quality of life (HRQOL) in stroke patients. However, the HRQOL in stroke patients (HRQOLISP) questionnaire is valid and exceptionally comprehensive. Founded on a holistic model of human life, it comprises both physical and spiritual spheres. However, its 102-item length may discourage routine use. Therefore, the aim was to determine the psychometric attributes of a shortened version based on a multicultural transnational study.

METHODS

HRQOLISP was administered to 100 stroke patients in Ibadan, 103 in Berlin, and control groups of 100 apparently healthy adults in Ibadan and 50 in Berlin. Analyzing data from both cities, items were reduced to 40. Construct validity of the resulting HRQOLISP-40 was assessed by comparison with the National Institutes of Health Stroke Scale (NIHSS), Stroke Levity Scale (SLS), modified Rankin Scale (mRS), and Short Form 36 (SF-36) Health Survey.

RESULTS

In multicultural settings, the HRQOLISP-40 showed good internal consistency (α = .76, .86) and test-retest reliability. It retained its discriminant validity between stroke and healthy participants and demonstrated good "known-groups" validity in its relationship to the SLS, NIHSS, and mRS in the physical sphere. The physical sphere showed good convergent validity with corresponding facets of the SF-36.

CONCLUSIONS

Despite item reduction, the HRQOLISP-40 demonstrated excellent psychometric properties and is valid for routine use and clinical trials in stroke. The relative preservation of the spiritual sphere demonstrated the concept of disability disparity. Its ability to simultaneously assess the physical and spiritual spheres may be beneficial in studies aimed at potentiating internal adaptation in stroke patients.