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

Comparison of psychometric properties of the dual-task timed up-and-go test (cognitive) and the 3-m walk backward test in community-dwelling stroke patients

BACKGROUND

There is a need for practical, easy-to-use and accurately assessing balance tools in stroke patients.

OBJECTIVES

This study aimed to compare the psychometric properties of the dual-task Timed Up-and-Go test (cognitive) (DTUG) and the 3-m walk backward test (3MBWT) in stroke patients.

METHODS

This study evaluated the practicality, validity, and reliability of the DTUG and the 3MBWT. The test-retest method was used for reliability. The Modified Four Square Step Test (MFSST), the Timed Up-and-Go (TUG), and Berg Balance Scale (BBS) were administered for concurrent validity. A cutoff value was calculated to discriminate between fallers and non-fallers.

RESULTS

The mean practicality times of the tests were 63.58 ± 47.32 sec for DTUG and 37.42 ± 24.036 sec for 3MBWT. Intraclass correlation coefficient of the DTUG and 3MBWT were 0.977, 0.964, respectively which showed excellent test - retest reliability. The DTUG demonstrated strong/very strong correlations with the MFSST (r = 0.724, p < 0.001), TUG (r = 0.909, p < 0.001), and BBS (r = -0.740, p < 0.001). The 3MBWT showed strong correlations with the MFSST (r = 0.835, p < 0.001), the TUG (r = 0.799, p < 0.001), and the BBS (r = -0.740, p < 0.001). The cutoff point was 36.945 s for DTUG and 14.605 s for 3MBWT.

CONCLUSIONS

The 3MBWT was a more practical test than the DTUG; however, the DTUG was more discriminative than the 3MBWT in identifying fallers after stroke.

CLINICAL TRIAL REGISTRATION NUMBER

NCT05211349.

URL

https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000BRKZ&selectaction=Edit&uid=U0005GRO&ts=2&cx=z21bhg.

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

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

Effects of the different intensities of task-oriented training on the upper extremity motor function and self-care ability of stroke survivors: study protocol for a multiarm parallel-group randomised controlled trial in a tertiary hospital in China

INTRODUCTION

Although task-oriented training (TOT) may provide added therapeutic value to stroke survivors, current TOT guidance offers insufficient advice on standardisation, particularly choices of intensity, for clinical practice. Therefore, this study aims to explore the effects of different intensities of TOT on motor function and self-care ability of stroke survivors.

METHODS AND ANALYSIS

This randomised controlled clinical trial will recruit 72 participants from a tertiary hospital, diagnosed with decreased self-care ability and upper limb motor dysfunction post-stroke. All participants will be randomly assigned to one of three experimental groups or the control group to undergo intervention for 8 weeks. The participants in the control group (n=18) will receive traditional occupational therapy, while those in the experimental groups will receive different intensities of TOT (50%, 75% and 100% intensity for groups A, B and C, respectively). This protocol designed a more innovative and optimised TOT programme to explore the optimal intensity of TOT on stroke survivors. The primary outcome is Canadian Occupational Performance Measure, and the secondary outcomes include Modified Barthel Index, Wolf Motor Function Test and Motor Activity Log.

ETHICS AND DISSEMINATION

The Second Affiliated Hospital of Hainan Medical University Ethics Committee approved the medical and ethical protocol for this study (LW2022015). All participants will sign an informed consent form. The results will be presented in scientific conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2200056390.

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

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

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

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

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

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Functional independence measured in the acute phase of stroke predicts both generic and specific health-related quality of life: a 3-month prospective study in a middle-income country

PURPOSE

To identify acute predictors of both generic and specific health-related quality of life (HRQoL) 3 months after stroke in individuals from a middle-income country.

MATERIALS AND METHODS

A 3-month prospective study with individuals who had suffered their first stroke, without previous disability, discharged from a stroke unit. The dependent outcomes, assessed 3 months after stroke, were generic and specific HRQoL (SF-36 and SSQOL total scores, respectively). The predictors assessed in the stroke unit were age, sex, education level, duration of hospital stay, current living arrangement, stroke severity (National Institutes of Health Stroke Scale-NIHSS), functional independence (Modified Barthel Index-MBI), motor impairment (Fugl-Meyer Assessment), and lower- and upper-limb residual muscle strength deficits. Linear multiple regression analyses were employed to identify predictors of both generic (model-1) and specific (model-2) HRQoL (α = 5%).

RESULTS

One hundred twenty-six individuals were assessed at 3-month post-stroke (61.3 ± 13.6 years). Regression analysis showed that functional independence was the best predictor of both generic (R2 = 21%; F = 34.82; p < 0.001) and specific (R2 = 29%; F = 51.71; p < 0.001) HRQoL at 3-month post-stroke.

CONCLUSION

Both generic and specific HRQoL at 3-month post-stroke can be predicted by functional independence assessed in the acute phase with the MBI.

PHQ-9 DIAGNOSTIC ACCURACY AND OPTIMAL CUT-OFF FOR DEPRESSION AMONG PATIENTS WITH STROKE IN NIGERIA

Background

Depression is one of the most common and devastating consequences among stroke survivors. In spite of the availability of treatment for depression, the non- or under-detection precludes patients from benefiting from it.

Objectives

This study sought to validate the Patient Health Questionnaire (PHQ- 9) as a tool for detecting depression among patients with stroke.

Methodology

A cross-sectional design comprising of adult patients diagnosed with stroke, who were attending the Neurology out-patient clinic of the University of Port Harcourt Teaching Hospital was employed in the study. The Receiver Operator Characteristics (ROC) curve and validity tests were performed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID-DSM IV) as the gold standard. The optimal PHQ-9 cut-off was determined using Youden Index. Kappa statistics was performed at p<0.05.

Results

The study had a total of 197 stroke cases with PHQ-9 and SCID-DSM IV findings. The median age was 54 years (range: 35-76 years). ROC Curve for PHQ-9 revealed an Area under the Curve (AUC) value of 0.93(95% CI: 0.88- 0.98). The optimal cut off value of six was obtained based on Youden Index. Sensitivity, specificity, positive predictive and negative predictive values at the optimal cut-off were 88.7%, 93.1%, 82.5% and 95.7% respectively. The Kappa statistics yielded 0.80 (95% CI: 0.68-0.86).

Conclusion

PHQ-9 is a useful screening tool for identifying depression among patients with stroke. An optimal cut-off score of six for PHQ-9 should be adopted for patients with stroke in Nigeria to identify depression, and the provision of holistic care.

Effects of a transitional home-based care program for stroke survivors in Harbin, China: a randomized controlled trial

BACKGROUND

China has the biggest stroke burden in the world. Continued measures have been taken to enhance post-stroke rehabilitation management in the last two decades. The weak link is with home-based rehabilitation, with more attention and resources devoted to inpatient rehabilitation.

OBJECTIVE

to address the service gap, this study tested a home-based transitional care model for stroke survivors.

METHODS

a randomized controlled trial was conducted from February 2019 to May 2020 in Harbin, China, involving 116 patients with ischemic stroke. The intervention group participants (n = 58, 50%) received a 12-week home-based care program with components of transitional care measures and the national guidelines for facilitating patients to perform home-based exercises with continued monitoring and gradual progression. Control group participants received standard care including medication advice, rehabilitation exercise and one nurse-initiated follow-up call. Data were collected at baseline and after a 90-day (post-intervention) and a 180-day (post-intervention) follow-up. The primary outcome was quality of life (QOL), measured using the EuroQol-Five Dimension 5-Level scale (EQ-5D-5L).

RESULTS

both intervention and control groups showed improvement in EQ-5D-5L from baseline to post-intervention (0.66 versus 0.83, P < 0.001) and (0.66 versus 0.77, P < 0.001), respectively, and there was significant group-by-time interaction in EuroQol-Visual Analogue Scale from baseline to post-intervention at 90 days and follow-up at 180 days with the intervention group experiencing better improvement. Similarly, significant interaction effects were also found in the Stroke Impact Symptom scale, self-efficacy and modified Barthel Index.

CONCLUSIONS

home-based transitional care was effective in improving QOL, symptoms, self-efficacy and activities of daily living.