Post stroke health-related quality of life, stroke severity and function: A longitudinal cohort study

Gait speed at the acute phase predicted health-related quality of life at 3 and 12 months after stroke: a prospective cohort study

OBJECTIVE

To investigate the association between acute-phase gait speed and health-related quality of life (HRQoL) at 3 and 12 months post-stroke.

DESIGN

Prospective cohort study.

SUBJECTS/PATIENTS

1,475 patients with first-ever ischaemic stroke.

METHODS

The patients were divided into 3 groups according to tertiles of gait speed, namely ≤0.8, 0.8-1.1, ≥1.1 m/s. Gait speed was assessed by the 10-m walking test within 2 weeks of hospitalization for acute stroke and before the rehabilitation programme. HRQoL measurements include the 3-level EuroQol five dimensions (EQ-5D-3L) index and EuroQoL visual analogue scale (EQ-VAS) scores. Linear and logistic regression analyses were used to identify associations between gait speed and HRQoL.

RESULTS

Adjusted for all covariates, the highest gait speed tertile group were associated with higher EQ-5D-3L index (B = 0.0303 and B = 0.0228, respectively, p < 0.001), and higher EQ-VAS (B = 3.3038 and B = 3.8877, respectively, p < 0.001), and lower odds of having problems with mobility (OR = 2.55 [95% CI: 0.141-0.458] and 0.485 [0.289-0.812], respectively, p < 0.01), self-care (OR = 0.328 [95% CI: 0.167-0.646] and 0.412 [0.217-0.784], respectively, p < 0.01), and usual activities (OR = 0.353 [95% CI: 0.211-0.590] and 0.325 [0.198-0.536], respectively, p < 0.0001) at 3 and 12 months, and pain/discomfort at 12 months (OR = 0.558 [95% CI:0.335-0.930], p < 0.05).

CONCLUSION

Acute-phase gait speed was predictive of post-stroke HRQoL at 3 and 12 months, especially when associated with domain-specific EQ-5D-3L.

The feasibility, repeatability, validity and responsiveness of the EQ-5D-3L in Krio for patients with stroke in Sierra Leone

OBJECTIVES

To assess the feasibility, repeatability, validity and responsiveness of the EQ-5D-3L in Krio for patients with stroke in Sierra Leone, the first psychometric assessment of the EQ-5D-3L to be conducted in patients with stroke in Sub Saharan Africa.

METHODS

A prospective stroke register at two tertiary government hospitals recruited all patients with the WHO definition of stroke and followed patients up at seven days, 90 days and one year post stroke. The newly translated EQ-5D-3L, Barthel Index (BI), modified Rankin Scale (mRS) and National Institute of Health Stroke Scale (NIHSS), a measure of stroke severity, were collected by trained researchers, face to face during admission and via phone at follow up. Feasibility was assessed by completion rate and proportion of floor/ceiling effects. Internal consistency was assessed by inter item correlations (IIC) and Cronbach's alpha. Repeatability of the EQ-5D-3L was examined using test-retest, EQ-5D-3L utility scores at 90 days were compared to EQ-5D-3L utility scores at one year in the same individuals, whose Barthel Index had remained within the minimally clinical important difference. Known group validity was assessed by stroke severity. Convergent validity was assessed against the BI, using Spearman's rho. Responsiveness was assessed in patients whose BI improved or deteriorated from seven to 90 days. Sensitivity analyses were conducted using the UK and Zimbabwe value sets, to evaluate the effect of value set, in a subgroup of patients with no formal education to evaluate the influence of patient educational attainment, and using the mRS instead of the BI to evaluate the influence of utilising an alternative functional scale.

RESULTS

The EQ-5D-3L was completed in 373/460 (81.1%), 360/367 (98.1%) and 299/308 (97.1%) eligible patients at seven days, 90 days and one year post stroke. Missing item data was low overall, but was highest in the anxiety/depression dimension 1.3% (5/373). Alpha was 0.81, 0.88 and 0.86 at seven days, 90 days and one year post stroke and IIC were within pre-specified ranges. Repeatability of the EQ-5D-3L was moderate to poor, weighted Kappa 0.23-0.49. EQ-5D-3L utility was significantly associated with stroke severity at all timepoints. Convergent validity with BI was strong overall and for shared subscales. EQ-5D-3L was moderately responsive to both improvement Cohen's D 0.55 (95% CI:0.15-0.94) and deterioration 0.92 (95% CI:0.29-1.55). Completion rates were similar in patients with no formal education 148/185 (80.0%) vs those with any formal education 225/275 (81.8%), and known group validity for stroke severity in patients with no formal education was strong. Using the Zimbabwe value set instead of the UK value set, and using the mRS instead of the BI did not change the direction or significance of results.

CONCLUSIONS

The EQ-5D-3L for stroke in Sierra Leone was feasible, and responsive including in patients with no formal education. However, repeatability was moderate to poor, which may be due to the study design, but should add a degree of caution in the analysis of repeated measures of EQ-5D-3L over time in this population. Known group validity and convergent validity with BI and mRS were strong. Further research should assess the EQ-5D in the general population, examine test-retest reliability over a shorter time period and assess the acceptability and validity of the anxiety/depression dimension against other validated mental health instruments. Development of an EQ-5D value set for West Africa should be a research priority.

Health-Related Quality of Life of Post-Stroke Patients in a Public Hospital

This study aimed to identify the correlation between influencing factors of activities of daily living (ADLs), mental health, and health-related quality of life (HRQoL) among post-stroke patients who enrolled in a transitional care service in a public hospital. This cross-sectional study involved 67 stroke patients who were enrolled in a transitional care service and visited the outpatient clinic at a public hospital in Seoul between March and December 2022. Their general characteristics, ADLs, mental health, and HRQoL were assessed. The data were analyzed using independent samples t-tests, analysis of variance, and Pearson correlation analysis, and the influencing factors were analyzed using regression analysis. HRQoL showed a statistically significant difference between patients living in different types of arrangements (t = 2.50, p = 0.015), and patients scores on the modified Rankin Scale (t = 7.08, p < 0.001). HRQoL was also significantly correlated with ADLs and mental health in stroke patients (r = -0.59, p < 0.001; r = -0.41, p < 0.001, respectively). Meanwhile, stroke severity (β = -0.30, p = 0.002), living arrangements (β = -0.30, p = 0.009) and ADLs (β = -0.45, p < 0.001) were found to influence HRQoL (F = 6.87, p < 0.001, R2 = 0.47). Reduced dependence for ADLs, improvements in symptoms consequent to stroke, and support related to living arrangements contributed to improved HRQoL and interventions for post-stroke patients in the transitional care service of a public hospital.

An machine learning model to predict quality of life subtypes of disabled stroke survivors

OBJECTIVE

Stroke causes serious physical disability with impaired quality of life (QoL) and heavy burden on health. The goal of this study is to explore the impaired QoL typologies and their predicting factors in physically disabled stroke survivors with machine learning approach.

METHODS

Non-negative matrix factorization (NMF) was applied to clustering 308 physically disabled stroke survivors in rural China based on their responses on the short form 36 (SF-36) assessment of quality of life. Principal component analysis (PCA) was conducted to differentiate the subtypes, and the Boruta algorithm was used to identify the variables relevant to the categorization of two subtypes. A gradient boosting machine(GBM) and local interpretable model-agnostic explanation (LIME) algorithms were used to apply to interpret the variables that drove subtype predictions.

RESULTS

Two distinct subtypes emerged, characterized by short form 36 (SF-36) domains. The feature difference between worsen QoL subtype and better QoL subtype was as follows: role-emotion (RE), body pain (BP) and general health (GH), but not physical function (PF); the most relevant predictors of worsen QoL subtypes were help from others, followed by opportunities for community activity and rehabilitation needs, rather than disability severity or duration since stroke.

INTERPRETATION

The results suggest that the rehabilitation programs should be tailored toward their QoL clustering feature; body pain and emotional-behavioral problems are more crucial than motor deficit; stroke survivors with worsen QoL subtype are most in need of social support, return to community, and rehabilitation.

The development of the People with Aphasia and Other Layperson Involvement (PAOLI) framework for guiding patient and public involvement (PPI) in aphasia research

BACKGROUND

Patient and Public Involvement (PPI) in aphasia research requires researchers to include people with aphasia as research partners from the beginning of the study. Yet the quality of reporting on the level and type of involvement is poorly documented in the absence of a framework to guide PPI in aphasia research. This study aimed to extract the items and statements relevant for the development of the People with Aphasia and Other Layperson Involvement (PAOLI) framework for designing and implementing PPI in aphasia research, in collaboration with people with aphasia.

METHOD

The method recommended by the EQUATOR network was followed. This involved: (1) evidence from a scoping review, (2) a thematic analysis of the in-depth interviews, of people with stroke and aphasia, on the topics to be included in the pilot draft, (3) a two round Delphi survey for item/statement selection and (4) an experts' consensus meeting. The research team involved two PPI partners with chronic stroke-induced aphasia. The research process involved co-design and was informed by the Dialogue model.

RESULTS

Twenty-three panellists, from 13 countries, voted in round one with 87% (20/23) responding in round two. The final PAOLI framework includes the following 17 items (with 66 descriptive statements): establish collaborations, recruit patients, gain informed consent, organize induction meetings, train patient partners, create communication links, engage communication partners, conceptualize topics, establish research priorities, reach consensus, work with co-design methods, develop proposals, assist with dissemination of results, promote implementation of the outcomes, support patient partners and promote self-evaluation, monitor progress and assess impact of the patient involvement. These items were considered by the panellists as the most relevant for the involvement of people with aphasia as research partners.

CONCLUSION

The PAOLI is the first international consensus framework for guiding patient involvement in aphasia research. Researchers are encouraged to adopt the framework to improve the quality of their research by promoting the meaningful involvement of people with aphasia within the research team from the start.

Botulinum Toxin and Dynamic Splint Restore Grasping Function after Stroke: A Case Report

Evidence on the effectiveness of upper extremity rehabilitation post-stroke is inconclusive. We evaluated a tailored therapeutic program with dynamic splint and botulinum toxin injections for the treatment of upper extremity muscle spasticity. A case of a 43-year-old woman with chronic spastic hemiparesis after ischemic stroke with significant mobility impairment in the left upper extremity was described. A 16-week program consisted of three 50-min sessions daily and focused on grasping and releasing with and without the splint. The patient was evaluated before botulinum toxin injection and after 6, 12 and 16 weeks according to the International Classification of Functioning, Disability and Health, and included the following scales: Fugl-Meyer Upper Extremity Assessment (FMA-UE), Modified Ashworth Scale, Numerical Rating Scale (NRS), MyotonPro, Stroke Impact Scale, Box and Blocks. Photographic documentation made before and after the experiment was compared. Motor functions improved by 19.7% on FMA-UE, spasticity was reduced by one degree and pain at rest and during activity decreased by one score on NRS. A reduction in the oscillation frequency of the relaxed muscle and the stiffness of the examined muscles was observed. The patient regained grasping function. Health-related quality of life was systematically improving with a 35% increase at week 16 compared to the baseline. The combination treatment for spasticity based on botulinum toxin and SaeboFlex^® dynamic splint in a patient with chronic spastic hemiparesis reduces disability and improves quality of life. However, further research is needed to investigate the treatment results.

Mediating effect of post-stroke depression between activities of daily living and health-related quality of life: meta-analytic structural equation modeling

BACKGROUND

Stroke survivors face various problems that affect their health-related quality of life (HRQoL). Reduced activities of daily living (ADL) may contribute to post-stroke depression (PSD) and low HRQoL, and depression might be associated with low HRQoL. However, these relationships are not well known. This study aimed to analyze correlations among ADL, PSD, and HRQoL in stroke survivors and further explore the mediating role of PSD between ADL and HRQoL.

METHODS

This study utilized meta-analytic structural equation modeling (MASEM) on systematically searched articles from six electronic databases, namely PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure (China), Wanfang database (China), and SinoMed (China), from inception up to July 31, 2021. Two researchers independently assessed study eligibility, and data from the eligible studies were encoded and assessed for quality. MASEM was utilized to examine correlations among ADL, PSD, and HRQoL, with an estimation of a pooled correlation matrix under a random-effects model. The matrix was directly fitted to a structural equation model using webMASEM.

RESULTS

In total, 8580 articles were screened, and data from 27 studies involving 33 effect sizes were used in the MASEM analysis. Correlations among the three variables were significant (both P < 0.01). Furthermore, PSD partially mediated the correlation between ADL and HRQoL (β = 0.24, 95% confidence interval 0.15-0.30).

CONCLUSIONS

The findings suggest that both decreased ADL and PSD may reduce HRQoL, while a decrease in ADL tends to cause depression after stroke. Therefore, ADL and PSD reductions should be improved to achieve better HRQoL of stroke survivors. Future studies should continue to discuss other factors affecting HRQoL to achieve optimal recovery in stroke survivors.

Functioning Problems Associated with Health Conditions with Greatest Disease Burden in South Africa: A Scoping Review

A notable rise in health-related disability for which evidence-based rehabilitation is beneficial is evident in low-to-middle income countries. This scoping review aimed to systematically identify and map the most common functioning problems associated with health conditions that contribute most to disability in South Africa using the International Classification of Functioning, Disability and Health (ICF) framework. Peer-reviewed evidence published from January 2006 to December 2021 was systematically searched from five databases. Some 268 studies reporting on functioning problems (impairments, activity limitations, and participation restrictions) in South African adults (>18 years) related to 10 health conditions were included. A total of 130 different functioning problems were mapped to the ICF. The most prevalent problems (top 20) were related to mobility, pain, and mental health but spanned across several ICF domains and were mostly in patients at primary care. The high prevalence and wide range of functioning problems may be particularly burdensome on an already strained primary health care (PHC) system. This points towards targeted planning of innovative strategies towards strengthening rehabilitation service delivery at primary care to address these complexities where there is an inadequate rehabilitation workforce.

Mediating Effects of Rehabilitation Motivation between Social Support and Health-Related Quality of Life among Patients with Stroke

Post-stroke health-related quality of life (HRQoL) is poor, which is related to low social support levels and lack of rehabilitation motivation. However, there are limited studies that have systematically analyzed the mechanisms underlying this relationship in stroke patients. This study aimed to identify the mediating effects of rehabilitation motivation on the relationship between social support and HRQoL among stroke patients. A cross-sectional descriptive study was conducted on 176 Koreans aged ≥19 years who were admitted for rehabilitation treatment after stroke at three general hospitals in Jeonbuk. Data collection was conducted from September to December 2020 through face-to-face interviews using structured questionnaires and review of medical records. The significance of the mediation model was tested using SPSS 25.0 and the PROCESS macro for SPSS v3.5. Significant associations were identified between social support and HRQoL. Our findings revealed an indirect effect, suggesting that the effects of social support on HRQoL are mediated by rehabilitation motivation (B = 0.004, 95% bias-corrected bootstrap confidence interval = 0.002, 0.006). Social support for stroke patients had a positive effect on HRQoL, and rehabilitation motivation was found to have a partial mediating effect on this relationship. This study suggests that social support from healthcare professionals and families for post-stroke can improve patients' HRQoL by inducing positive rehabilitation motivation. Therefore, developing intervention strategies to motivate rehabilitation could improve the HRQoL of patients with stroke.