Predictors of Burden for First-Ever Stroke Survivor's Long-Term Caregivers: A Study of KOSCO.

Long-term changes in caregiver burden should be clarified considering that extended post-stroke disability can increase caregiver stress. We assessed long-term changes in caregiver burden severity and its predictors. This study was a retrospective analysis of the Korean Stroke Cohort for Functioning and Rehabilitation. Patients with an acute first-ever stroke were enrolled from August 2012 to May 2015. Data were collected at 6 months and 6 years after stroke onset. The caregiver burden was measured with a subjective caregiver burden questionnaire based on the Korean version of the Caregiver Burden Inventory. The caregivers' characteristics and patients' clinical and functional status were also examined at each follow-up. A high caregiver burden, which suggests a risk of burnout, was reported by 37.9% and 51.7% of caregivers at 6 months and 6 years post-stroke, respectively. Both the caregiver burden total score and proportion of caregivers at risk of burnout did not decrease between 6 months and 6 years. The patients' disability (OR = 11.60; 95% CI 1.58-85.08; p = 0.016), caregivers' self-rated stress (OR = 0.03; 95% CI 0.00-0.47; p = 0.013), and caregivers' quality of life (OR = 0.76; 95% CI 0.59-0.99; p = 0.042) were burden predictors at 6 months. At 6 years, only the patients' disability (OR = 5.88; 95% CI 2.19-15.82; p < 0.001) and caregivers' psychosocial stress (OR = 1.26; 95% CI 1.10-1.44; p = 0.001) showed significance. Nearly half of the caregivers were at risk of burnout, which lasted for 6 years after stroke onset. The patients' disability and caregivers' stress were burden predictors in both subacute and chronic phases of stroke. The findings suggest that consistent interventions, such as emotional support or counseling on stress relief strategies for caregivers of stroke survivors, may reduce caregiver burden. Further research is needed to establish specific strategies appropriate for Korean caregivers to alleviate their burden in caring for stroke patients.

Factors and predictive model for malnutrition in poststroke disabled patients: A multicenter cross-sectional study.

BACKGROUND: Although malnutrition has been shown to influence the clinical outcome of poststroke disabled patients, the associated factors and the prediction model have yet to be uncovered. OBJECTIVES: This study aims to assess the current prevalence and factors associated with malnutrition in poststroke disabled patients and establish a prediction model. METHODS: A multicenter cross-sectional survey among Chinese poststroke disabled patients (≥18 y old) was conducted in 2021. Information on patients' basic data, medical history, Barthel Index, dysphagia, and nutritional status was collected. A multivariable logistic regression model was used to identify the factors that influence malnutrition. Nomogram was developed and internal validation was conducted using 5-fold cross-validation. External validation was performed using the data from a preliminary survey. Receiver operating characteristic (ROC) analysis, calibration curves, and decision curve analysis (DCA) were used to analyze the predictive value of the nomogram. RESULTS: Four hundred fifty-seven cases were enrolled, with the prevalence of malnutrition as 71.77%. Age (aOR = 1.039, 95% CI: 1.006-1.078), pulmonary infection (aOR = 4.301, 95% CI: 2.268-14.464), dysphagia (aOR = 24.605, 95% CI: 4.966-191.058), total intake volume (aOR = 0.997, 95% CI: 0.995-0.999), Barthel Index (aOR = 0.965, 95% CI: 0.951-0.980), and nasogastric tube (aOR = 16.529, 95% CI: 7.418-52.518) as nutrition support mode (compared to oral intake) were identified as the associated factors of malnutrition in stroke-disabled patients (P < 0.05). ROC analysis showed that the area under the curve (AUC) for nomogram was 0.854 (95% CI: 0.816-0.892). Fivefold cross-validation showed the mean AUC as 0.829 (95% CI: 0.784-0.873). There were no significant differences between predicted and actual probabilities. The DCA revealed that the model exhibited a net benefit when the risk threshold was between 0 and 0.4. CONCLUSIONS: Age, pulmonary infection, dysphagia, nutrition support mode, total intake volume, and Barthel Index were factors associated with malnutrition in stroke-related disabled patients. The nomogram based on the result exhibited good accuracy, consistency and values.

Stroke rehabilitation pathways during the first year: A cost-effectiveness analysis from a cohort of 460 individuals.

BACKGROUND: Stroke burden challenges global health, and social and economic policies. Although stroke recovery encompasses a wide range of care, including in-hospital, outpatient, and community-based rehabilitation, there are no published cost-effectiveness studies of integrated post-stroke pathways. OBJECTIVE: To determine the most cost-effective rehabilitation pathway during the first 12 months after a first-ever stroke. METHODS: A cohort of people in the acute phase of a first stroke was followed after hospital discharge; 51 % women, mean (SD) age 74.4 (12.9) years, mean National Institute of Health Stroke Scale score 11.7 (8.5) points, and mode modified Rankin Scale score 3 points. We developed a decision tree model of 9 sequences of rehabilitation care organised in 3 stages (3, 6 and 12 months) through a combination of public, semi-public and private entities, considering both the individual and healthcare service perspectives. Health outcomes were expressed as quality-adjusted life years (QALY) over a 1-year time horizon. Costs included healthcare, social care, and productivity losses. Sensitivity analyses were conducted on model input values. RESULTS: From the individual perspective, pathway 3 (Short-term Inpatient Unit ¼ Community Clinic) was the most cost-effective, followed by pathway 1 (Rehabilitation Centre ¼ Community Clinic). From the healthcare service perspective, pathway 3 was the most cost-effective followed by pathway 7 (Outpatient Hospital ¼ Private Clinic). All other pathways were considered strongly dominated and excluded from the analysis. The total 1-year mean cost ranged between €12104 and €23024 from the individual's perspective and between €10992 and €31319 from the healthcare service perspective. CONCLUSION: Assuming a willingness-to-pay threshold of one times the national gross domestic product (€20633/QALY), pathway 3 (Short-term Inpatient Unit ¼ Community Clinic) was the most cost-effective strategy from both the individual and healthcare service perspectives. Rehabilitation pathway data contribute to the development of a future integrated care system adapted to different stroke profiles.

Assessing care dependence status and associated influencing factors among middle-aged hemiplegic stroke patients during the post-acute rehabilitation phase: A correlational study.

AIMS: To comprehensively examine the prevailing condition of care dependence among middle-aged individuals who have experienced hemiplegia subsequent to a stroke and were currently undergoing post-acute rehabilitation. Additionally, the study sought to analyse the determinants that impacted this phenomenon. DESIGN: A single-centre, cross-sectional study design. METHODS: During the period from January 2020 to October 2022, a cohort of 196 hemiplegic stroke patients, aged between 40 and 65, and within 6 months of their stroke onset, was selected from the cerebrovascular outpatient clinic at a tertiary hospital in Hangzhou. The demographic and disease-related data, care dependence level, mental state, nutrition and depression status were collected. Furthermore, all collected data were analysed by descriptive and correlative statistical methods. RESULTS: The care dependence level was 51.04 ± 9.42, with an incidence of care dependence of 78.1%. Multivariate regression analysis showed that age, history of falls, physical dysfunction, chronic comorbidities, depression, nutritional status and cognitive dysfunction were influencing factors for care dependence in the participants after a stroke. CONCLUSION: The incidence of care dependence among hemiplegic patients aged from 40 to 65 years old in the early stage after a stroke was high. Nursing staff should focus on these patients with a history of falling, physical dysfunction, comorbidity, depression status, nutritional status and cognitive dysfunction in clinical practice. RELEVANCE TO CLINICAL PRACTICE: The incidence of care dependence in middle-aged hemiplegic patients following a stroke is significantly increased. Some risk factors should be assessed, monitored, and controlled by nursing staff as early as possible in order to reduce the dependence levels in post-acute rehabilitation period and improve the quality of life of hemiplegia patients. REPORTING METHOD: Our study complies with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Checklist: cross-sectional studies (see Table S1). PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Neighborhood socioeconomic disadvantage measures in rehabilitation clinical trials: Lessons learned in recruitment.

PURPOSE: The Area Deprivation Index (ADI) measures the relative disadvantage of an individual or social network using US Census indicators. Although a strong re-hospitalization predictor, ADI has not been routinely incorporated into rehabilitation research. The purposes of this paper are to examine the use of ADI related to study recruitment, association with carepartner psychosocial factors, and recruitment strategies to increase participant diversity. METHODS: Descriptive analysis of baseline data from a pilot stroke carepartner-integrated therapy trial. Participants were 32 carepartners (N = 32; 62.5 % female; mean age 57.8 ± 13.0 years) and stroke survivors (mean age (60.6 ± 14.2) residing in an urban setting. Measures included ADI, Bakas Caregiver Outcome Scale, Caregiver Strain Index, and Family Assessment Device. RESULTS: Most carepartners were Non-Hispanic White participants (61.3 %), part or fully employed (43 %), with >$50,000 (67.7 %) income, and all had some college education. Most stroke survivors were Non-Hispanic White participants (56.3 %) with some college (81.3 %). Median ADI state deciles were 3.0 (interquartile range 1.5-5, range 1-9), and mean national percentiles were 41.7 ± 23.5 with only 6.3 % of participants from the most disadvantaged neighborhoods. For the more disadvantaged half of the state deciles, the majority were Black or Asian participants. No ADI and carepartner factors were statistically related. CONCLUSIONS: The use of ADI data highlighted a recruitment gap in this stroke study, lacking the inclusivity of participants from disadvantaged neighborhoods and with lower education. Using social determinants of health indicators to identify underrepresented neighborhoods may inform recruitment methods to target marginalized populations and broaden the generalizability of clinical trials.

Effect of Acupuncture and Rehabilitation Therapy on the Recovery of Neurological Function and Prognosis of Stroke Patients.

BACKGROUND: Stroke is a common cerebrovascular disease among the middle-aged and elderly, which can lead to a series of neurological disorders. Acupuncture is an important part of traditional Chinese medicine, with great value in improving the neurological deficits of stroke patients. In addition, rehabilitation therapy is also of great significance for alleviating the neurological deficits of patients and improving their activities of daily living. OBJECTIVE: To explore the effect of acupuncture and moxibustion combined with rehabilitation therapy on the recovery of neurological function and prognosis of stroke patients. METHODS: The case data of 100 stroke patients treated in the Wuhan Hospital of Traditional Chinese Medicine from January 2019 to July 2021 were analyzed retrospectively. According to the treatment plan patients received, they were divided into the following two groups: an observation group (n = 52) treated with acupuncture combined with rehabilitation therapy and a control group (n = 48) treated with rehabilitation therapy alone. The two groups were compared in terms of the following items: therapeutic efficacy, plasma levels of cortisol (Cor) and neuropeptide Y (NPY), nerve function, motor function, balance ability, self-care ability, swallowing function, negative emotions, and quality of life. RESULTS: The therapeutic effect of the observation group was significantly higher than that of the control group (P < 0.05). The levels of Cor and NPY, as well as the neurological function, motor function, balance ability, self-care ability, swallowing function, and negative emotions, were not significantly different between the two groups before treatment (P > 0.05). While after intervention, all the above indexes improved in both groups, with better improvements in the observation group compared with the control group (P < 0.05). And the various dimensions concerning the quality of life of patients were also significantly better in the observation group when compared with the control group. CONCLUSION: Acupuncture of traditional Chinese medicine combined with rehabilitation therapy has outstanding effects in stroke treatment and can effectively improve the neurological function, prognosis, and quality of life of patients, which is worthy of clinical promotion.

Medical Data Acquisition and Internet of Things Technology-Based Cerebral Stroke Disease Prevention and Rehabilitation Nursing Mobile Medical Management System.

This research was aimed at exploring the application value of a mobile medical management system based on Internet of Things technology and medical data collection in stroke disease prevention and rehabilitation nursing. In this study, on the basis of radio frequency identification (RFID) technology, the signals collected by the sensor were filtered by the optimized median filtering algorithm, and a rehabilitation nursing evaluation model was established based on the backpropagation (BP) neural network. The performance of the medical management system was verified in 32 rehabilitation patients with hemiplegia after stroke and 6 healthy medical staff in the rehabilitation medical center of the hospital. The results showed that the mean square error (MSE) and peak signal-to-noise ratio (PSNR) of the median filtering algorithm after optimization were significantly higher than those before optimization (P < 0.05). When the number of neurons was 23, the prediction accuracy of the test set reached a maximum of 89.83%. Using traingda as the training function, the model had the lowest training time and root mean squared error (RMSE) value of 2.5 s and 0.29, respectively, which were significantly lower than the traingd and traingdm functions (P < 0.01). The error percentage and RMSE of the model reached a minimum of 7.56% and 0.25, respectively, when the transfer functions of both the hidden and input layers were tansig. The prediction accuracy in stages III~VI was 90.63%. It indicated that the mobile medical management system established based on Internet of Things technology and medical data collection has certain application value for the prevention and rehabilitation nursing of stroke patients, which provides a new idea for the diagnosis, treatment, and rehabilitation of stroke patients.

Effects of Neuromuscular Electrical Stimulation Combined with Repetitive Transcranial Magnetic Stimulation on Upper Limb Motor Function Rehabilitation in Stroke Patients with Hemiplegia.

OBJECTIVE: To investigate the effect of neuromuscular electrical stimulation (NMES) combined with repetitive transcranial magnetic stimulation (rTMS) on upper limb motor dysfunction in stroke patients with hemiplegia. METHODS: A total of 240 stroke patients with hemiplegia who met the inclusion criteria were selected and randomly divided into 4 groups (60 cases in each group): control group, NMES group, rTMS group, and NMES + rTMS group. Before treatment and 4 weeks after treatment, we evaluated and compared the results including Fugl-Meyer assessment of upper extremity (FMA-UE) motor function, modified Barthel index (MBI), modified Ashworth scale (MAS), and motor nerve electrophysiological results among the 4 groups. RESULTS: Before treatment, there was no significant difference in the scores of FMA-UE, MBI, MAS, and motor nerve electrophysiological indexes among the four groups, with comparability. Compared with those before treatment, the scores of the four groups were significantly increased and improved after treatment. And the score of the NMES + rTMS group was notably higher than those in the other three groups. CONCLUSION: NMES combined with rTMS can conspicuously improve the upper extremity motor function and activities of daily life of stroke patients with hemiplegia, which is worthy of clinical application and promotion.

Association of material deprivation with discharge location and length of stay after inpatient stroke rehabilitation in Ontario: a retrospective, population-based cohort study.

BACKGROUND: Low socioeconomic status is associated with increased risk of stroke and worse poststroke functional status. The aim of this study was to determine whether socioeconomic status, as measured by material deprivation, is associated with direct discharge to long-term care or length of stay after inpatient stroke rehabilitation. METHODS: We performed a retrospective, population-based cohort study of people admitted to inpatient rehabilitation in Ontario, Canada, after stroke. Community-dwelling adults (aged 19-100 yr) discharged from acute care with a most responsible diagnosis of stroke between Sept. 1, 2012, and Aug. 31, 2017, and subsequently admitted to an inpatient rehabilitation bed were included. We used a multivariable logistic regression model to examine the association between material deprivation quintile (from the Ontario Marginalization Index) and discharge to long-term care, and a multivariable negative binomial regression model to examine the association between material deprivation quintile and rehabilitation length of stay. RESULTS: A total of 18 736 people were included. There was no association between material deprivation and direct discharge to long-term care (most v. least deprived: odds ratio [OR] 1.07, 95% confidence interval [CI] 0.89-1.28); however, people living in the most deprived areas had a mean length of stay 1.7 days longer than that of people in the least deprived areas (p = 0.004). This difference was not significant after adjustment for other baseline differences (relative change in mean 1.02, 95% CI 0.99-1.04). INTERPRETATION: People admitted to inpatient stroke rehabilitation in Ontario had similar discharge destinations and lengths of stay regardless of their socioeconomic status. In future studies, investigators should consider further examining the associations of material deprivation with upstream factors as well as potential mitigation strategies.

Long-Term Rehabilitation Utilization Pattern Among Stroke Patients Under the National Health Insurance Program.

OBJECTIVE: The aim of this study was to understand the frequency of patients receiving rehabilitation services at various periods after stroke and the possible medical barriers to receiving rehabilitation. DESIGN: A retrospective cohort study was conducted using a nationally representative sample in Taiwan. A total of 14,600 stroke patients between 2005 and 2011 were included. Utilization of physical therapy or occupational therapy at different periods after stroke onset was the outcome variable. Individual and geographic characteristics were investigated to determine their effect on patients' probability of receiving rehabilitation. RESULTS: More severe stroke or more comorbid diseases increased the odds of receiving physical therapy and occupational therapy; older age was associated with decreased odds. Notably, sex and stroke type influenced the odds of rehabilitation only in the early period. Copayment exemption lowered the odds of rehabilitation in the first 6 mos but increased the odds in later periods. Rural and suburban patients had significantly lower odds of receiving physical therapy and occupational therapy, as did patients living in areas with fewer rehabilitation therapists. CONCLUSIONS: Besides personal factors, geographic factors such as urban-rural gaps and number of therapists were significantly associated with the utilization of post-stroke rehabilitation care. Furthermore, the influence of certain factors, such as sex, stroke type, and copayment exemption type, changed over time.

Preexisting brain lesions in patients with post stroke pusher behavior and their association with the recovery period: A one year retrospective cohort study in a rehabilitation setting.

The presence of preexisting brain lesions due to previous stroke and cerebral small vessel disease has been reported to influence stroke related disability or rehabilitation outcomes. However, there is no data about the impact of such lesions on the recovery period after pusher behavior (PB). This retrospective cohort study aimed to determine the influence of preexisting brain lesions on PB recovery time. Nineteen patients who were suffering from PB were included in the study. The presence of preexisting brain lesions, including previous stroke, silent brain infarcts, microbleed, white matter hyperintensity, and enlarged perivascular spaces were assessed using medical history reports, radiological reports, and magnetic resonance imaging data. The lesion score, ranging from 0 to 5, was calculated based on each preexisting brain lesion. The time to recovery from PB was assessed using the Scale for Contraversive Pushing. Based on the median value of the lesion score, we divided patients into those with a lesion score < 2 and those with a lesion score ≥ 2. A Kaplan Meier survival analysis was performed between these two groups. A multivariable Cox proportional hazards analysis was also performed using the side with hemiparesis and the score of preexisting brain lesions as covariates to determine the hazard ratio. The results showed that the group with a lesion score ≥ 2 had significantly delayed recovery from PB and the hazard ratio of preexisting brain lesions score was 0.458 (95% confidence interval: 0.221, 0.949), while the side of hemiparesis was not identified a significant covariate. Our results indicated that patients with PB having higher score of preexisting brain abnormalities might require a longer time to recover, and this might be useful in planning inpatient rehabilitation and treatment goals for patients with PB.

Impact of Modified Cardiac Rehabilitation Within a Stroke Recovery Program on All-Cause Hospital Readmissions.

OBJECTIVE: A Stroke Recovery Program (SRP) including cardiac rehabilitation demonstrated lower all-cause mortality rates, improved cardiovascular function, and overall functional ability among stroke survivors. Neither an effect of SRP on acute care hospital readmission rates nor cost savings have been reported. DESIGN: This prospective matched cohort study included 193 acute stroke survivors admitted to an inpatient rehabilitation facility between 2015 and 2017. The 105 SRP participants and 88 nonparticipants were matched exactly for stroke type, sex, and race and approximately for age, baseline functional scores, and medical complexity scores. Primary outcome measured acute care hospital readmission rate up to 1 yr post-stroke. Secondary outcomes measured costs. RESULTS: A 22% absolute reduction (P = 0.006) in hospital readmissions was observed between the SRP participant (n = 47, or 45%) and nonparticipant (n = 59, or 67%) groups. This resulted in significant cost savings. The conventional care cost to the Center for Medicare and Medicaid Services for stroke patients for both readmissions and outpatient therapy is estimated at $9.67 billion annually. The yearly cost for these services with utilization of the SRP is $8.55 billion. CONCLUSION: Acute care hospital readmissions were reduced in stroke survivors who participated in SRP. Future study is warranted to examine whether widespread application of a similar program may improve quality of life and decrease cost.

Gait, balance, and functional independence level in stroke patients

Introduction: Most stroke patients present limited movement, which alters gait speed and balance. This study aimed to correlate balance and gait speed, and weight distribution and balance in post-stroke patients.Methods: In total, 36 participants were included. Data collection occurred as follows: filling out the assessment form; assessment with the Berg Balance Scale (BBS); assessment with the baropodometric platform; performing the 10 Meter Walk Test (10mWT) with accelerometer; measurements with the modified Rankin Scale (mRS); the Functional Ambulation Classification (FAC); and the Barthel Index (BI).Results: A negative correlation between FAC and mRS (r = −0.708; p < 0.05) and between BI and mRS (r = −0.716; p < 0.05) was found. The correlation between BI and FAC was positive (r = 0.591). There was a strong positive correlation between the 10mWT values and the BBS score (r = 0.708; p < 0.05). Moreover, a weak negative correlation was observed between BBS values and lower limb weight distribution (r = −0.378; p < 0.05).Conclusion: We found a correlation between the functional ambulation and the degree of independence.This study showed that the better the balance, the greater the gait speed, and the lower the difference on lower limbs weight distribution, the better the balance in post-stroke patients.

Experiences of stroke survivors and measurement of post stroke participation and activity across seasons-A mixed methods approach.

Participation and activity post stroke can be limited due to adverse weather conditions. This study aimed to: Quantify and compare summer and winter participation and activity, and explore how community dwelling people with stroke describe their feelings about their level of participation and activity by season. This embedded mixed-methods observational study took place in a city with weather extremes. Community dwelling individuals at least one year post-stroke, able to walk ≥50 metres +/- a walking aide were included. Evaluations and interviews occurred at participants' homes in two seasons: Reintegration to Normal living Index (RNL), Activities-specific Balance Confidence (ABC) and descriptive outcomes. Participants wore activity monitors for one week each season. Analysis included descriptive statistics, non-parametric tests and an inductive approach to content analysis. Thirteen individuals participated in quantitative evaluation with eight interviewed. Mean age 61.5 years, 62% female and mean 6.2 years post-stroke. No differences between winter-summer values of RNL, ABC, or activity monitor outcomes. However, participants felt they could do more and were more independent in summer. The winter conditions such as ice, snow, cold and wind restricted participation and limited activities. Nonetheless, many participants were active and participated despite the winter challenges by finding other ways to be active, and relying on social supports and personal motivation. The qualitative findings explained unexpected quantitative results. Participants described many challenges with winter weather, but also ways they had discovered to participate and be active despite these challenges. Changes to future studies into seasonal differences are suggested.

Self-Rehabilitation for Post-Stroke Motor Function and Activity-A Systematic Review and Meta-Analysis.

Background. Due to an increasing stroke incidence, a lack of resources to implement effective rehabilitation and a significant proportion of patients with remaining impairments after treatment, there is a rise in demand for effective and prolonged rehabilitation. Development of self-rehabilitation programs provides an opportunity to meet these increasing demands.Objective. The primary aim of this meta-analysis was to determine the effect of self-rehabilitation on motor outcomes, in comparison to conventional rehabilitation, among patients with stroke. The secondary aim was to assess the influence of trial location (continent), technology, time since stroke (acute/subacute vs chronic), dose (total training duration > vs ≤ 15 hours), and intervention design (self-rehabilitation in addition/substitution to conventional therapy) on effect of self-rehabilitation.Methods. Studies were selected if participants were adults with stroke; the intervention consisted of a self-rehabilitation program defined as a tailored program where for most of the time, the patient performed rehabilitation exercises independently; the control group received conventional therapy; outcomes included motor function and activity; and the study was a randomized controlled trial with a PEDro score ≥5.Results. Thirty-five trials were selected (2225 participants) and included in quantitative synthesis regarding motor outcomes. Trials had a median PEDro Score of 7 [6-8]. Self-rehabilitation programs were shown to be as effective as conventional therapy. Trial location, use of technology, stroke stage, and intervention design did not appear to have a significant influence on outcomes.Conclusion. This meta-analysis showed low to moderate evidence that self-rehabilitation and conventional therapy efficacy was equally valuable for post-stroke motor function and activity.

Stroke in Africa: profile, progress, prospects and priorities.

Stroke is a leading cause of disability, dementia and death worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability occur in low-income and middle-income countries. At the turn of the century, the most common diseases in Africa were communicable diseases, whereas non-communicable diseases, including stroke, were considered rare, particularly in sub-Saharan Africa. However, evidence indicates that, today, Africa could have up to 2-3-fold greater rates of stroke incidence and higher stroke prevalence than western Europe and the USA. In Africa, data published within the past decade show that stroke has an annual incidence rate of up to 316 per 100,000, a prevalence of up to 1,460 per 100,000 and a 3-year fatality rate greater than 80%. Moreover, many Africans have a stroke within the fourth to sixth decades of life, with serious implications for the individual, their family and society. This age profile is particularly important as strokes in younger people tend to result in a greater loss of self-worth and socioeconomic productivity than in older individuals. Emerging insights from research into stroke epidemiology, genetics, prevention, care and outcomes offer great prospects for tackling the growing burden of stroke on the continent. In this article, we review the unique profile of stroke in Africa and summarize current knowledge on stroke epidemiology, genetics, prevention, acute care, rehabilitation, outcomes, cost of care and awareness. We also discuss knowledge gaps, emerging priorities and future directions of stroke medicine for the more than 1 billion people who live in Africa.

Effect of Improvement in Sarcopenia on Functional and Discharge Outcomes in Stroke Rehabilitation Patients.

This cross-sectional study investigated the proportion of patients' recovery from sarcopenia status and the relationship between improvement in sarcopenia (IS) and function and discharge outcome in hospitalized patients with stroke. This study included patients with stroke, aged 65 years or more, with a diagnosis of sarcopenia, who were admitted to a convalescent rehabilitation ward. Sarcopenia was diagnosed according to the Asian Working Group for Sarcopenia 2019 criteria. Patients were divided according to the presence or absence of sarcopenia at discharge: IS group and non-improvement in sarcopenia (NIS) group. Among the 227 participants (mean age: 80.5 years; 125 females), 30% (69/227) of the patients were in the IS group, while 70% (158/227) were in the NIS group. The IS group showed a higher Functional Independence Measure (FIM) than the NIS group (median 112 vs. 101, p = 0.003). The results demonstrated that IS was independently associated with higher FIM (partial regression coefficient, 5.378; 95% confidence interval (CI), 0.709-10.047). The IS group had higher odds of home discharge than the NIS group (odds ratio, 2.560; 95% CI, 0.912-7.170). In conclusion, recovery from sarcopenia may be associated with better function in patients with stroke.

Methodological Challenges and Statistical Approaches in the COMprehensive Post-Acute Stroke Services Study.

BACKGROUND: The COMprehensive Post-Acute Stroke Services study was a cluster-randomized pragmatic trial designed to evaluate a comprehensive care transitions model versus usual care. The data collected during this trial were complex and analysis methodology was required that could simultaneously account for the cluster-randomized design, missing patient-level covariates, outcome nonresponse, and substantial nonadherence to the intervention. OBJECTIVE: The objective of this study was to discuss an array of complementary statistical methods to evaluate treatment effectiveness that appropriately addressed the challenges presented by the complex data arising from this pragmatic trial. METHODS: We utilized multiple imputation combined with inverse probability weighting to account for missing covariate and outcome data in the estimation of intention-to-treat effects (ITT). The ITT estimand reflects the effectiveness of assignment to the COMprehensive Post-Acute Stroke Services intervention compared with usual care (ie, it does not take into account intervention adherence). Per-protocol analyses provide complementary information about the effect of treatment, and therefore are relevant for patients to inform their decision-making. We describe estimation of the complier average causal effect using an instrumental variables approach through 2-stage least squares estimation. For all preplanned analyses, we also discuss additional sensitivity analyses. DISCUSSION: Pragmatic trials are well suited to inform clinical practice. Care should be taken to proactively identify the appropriate balance between control and pragmatism in trial design. Valid estimation of ITT and per-protocol effects in the presence of complex data requires application of appropriate statistical methods and concerted efforts to ensure high-quality data are collected.

Revisiting the Proportional Recovery Model in View of the Ceiling Effect of Fugl-Meyer Assessment.

Background and Purpose: The aim of this study was to verify the validity of the proportional recovery model in view of the ceiling effect of the Fugl-Meyer Assessment. Methods: We reviewed the medical records of patients enrolled in the Korean Stroke Cohort for Functioning and Rehabilitation between August 2012 and May 2015. Recovery proportion was defined as the actual change in Fugl-Meyer Assessment score of the upper extremity between 7 days and 6 months poststroke, relative to the initial neurological impairment. We then used logistic regression to identify clinical factors attributable to a ceiling effect of the Fugl-Meyer Assessment score of the upper extremity and propensity score matching to verify the validity of the proportional recovery rule. Results: We screened 10 636 patients and analyzed 849 patients (mean age, 65.4±11.9 years; female, 320 [37.7%]) with first-ever ischemic stroke. We found, through logistic regression analysis, that a one-unit increase in the initial neurological impairment and the age at stroke onset affected the odds ratio (1.0386 and 0.9736, respectively) of achieving the full Fugl-Meyer Assessment score of the upper limb at 6 months poststroke. We also demonstrated, through propensity score matching, that the difference in initial neurological impairment of the upper extremity resulted in discrepancy of the recovery proportion (0.92±0.20 [0­1] versus 0.81±0.31 [0­1], P<0.001). Conclusions: We demonstrated that the ceiling effect of the Fugl-Meyer Assessment score of the upper extremity is pronounced in patients with mild initial motor deficits of the upper extremity and that the recovery proportion varies according to the initial motor deficit of the upper limb using logistic regression analysis and propensity score matching, respectively. These results suggest that the proportional recovery model is not valid.