Identification Of Stroke Subtypes Based On Functional Performance Among Stroke Survivors

Background

The physical manifestations of stroke are heterogeneous in nature making it challenging to develop subgroups that are clinically useful with respect to intervention design and prognosis in stroke rehabilitation. To be able to develop appropriate interventions or make accurate predictions on prognosis during stroke rehabilitation, it may be important to identify functional subtypes among stroke survivors.

AIM

The aim of the study is to identify stroke subtypes based on functional performance among stroke survivors receiving treatment at two tertiary hospitals in Accra.

Method

This cross-sectional survey will involve a convenience sample of stroke survivors admitted to stroke units of the Korle Bu Teaching Hospital and Greater Accra Regional Hospital. A well-designed data capturing form to be hosted online (google form) will be used to collect demographic and clinical data. Functional assessments will be performed using the Functional Independence Measure (FIM) and Barthel Index (BI). Cluster analysis will be performed to classify patients into various subtypes using their functional performance scores.

Expected outcome

The findings from this study will help identify functional subtypes of stroke survivors. It is hoped that this knowledge will be clinically relevant to physiotherapists as it may inform developing of appropriate treatment plans and interventions to address specific functional performance deficits in this population.

Introduction

Stroke is the leading cause of death and the third leading cause of disability worldwide (Feigin, et al. , 2014). An estimated 17. 7 million lives were claimed as a result of CVDs in 2015, representing 31% of all global deaths. Out of these deaths, an estimated 7. 4 million were due to coronary heart disease and 6. 7 million were due to stroke (World Health Organisation, 2017). Globally, 70% of stroke and 87% of both stroke related deaths and disability adjusted life years occur in low and middle-income countries (Feigin, Lawes, Bennett, Barker-Collo, & Parag, 2009). Evidence provides that 8% of all first-ever stroke occurs in Africa and that 5% of the 30 million survivors worldwide live in Africa (Unwin & Alberti, 2006). Stroke ranks among the top three causes of mortality, and one of the most important cause of disability in Ghana (Wiredu & Nyame, 2001) . In a study conducted between 1983 to 2013, the rate of stroke admissions in Ghana increased progressively from 5. 32/1000 admissions in 1983 to 13. 85/1000 admissions in 2010 corresponding to a 260% rise over the period (Sarfo, et al. , 2015)

The increased prevalence of stroke in recent years will result in increased demands on health services as stroke survivors may have functional deficits (Baztána, et al. , 2007). According to Greshman, et al. (1975) an estimated two thirds of stroke survivors have residual neurological deficits that affects function and about 50% are left with disability rendering them dependent on others for activities of daily living (ADL). The physical manifestation of stroke is heterogenous in nature and varies with the particular region of the central nervous system (CNS) that has sustained the damage (Staines, Mcllory, & Brooks, 2009). Among the functional deficits of stroke, the most common is paralysis, which is mostly on one side of the body and may affect the face, arm and leg (National Institues of Health, 2014).

Rehabilitation remains one of the major cornerstones of treating stroke survivors and plays a very important role in reducing long term effect of stroke and achieving optimal functional recovery (Brewer, Horgan, Hickey, & William, 2013). The general classification of stroke; haemorrhagic and Ischaemic stroke and its subtypes gives little information on the functional abilities of stroke survivors. The focus of stroke rehabilitation borders on improving functional capabilities of stroke survivors and the available stroke classification and subtypes are based on the area and mechanism of injury rather than the functional abilities of stroke survivors. It is therefore essential to classify stroke patients based on their functional performance.

The study seeks to identify stroke subtypes based on functional performance among stroke survivors receiving treatment at two tertiary hospitals in Accra.

Problem statement

Physiotherapy is one of the highly sought-after rehabilitation services among stroke survivors for organised care (Langhorne, Legg, Pallock, & Sellars, 2002). This is because of the positive impact physiotherapy treatment has on functional recovery and quality of life (Pollock, Baer, Pomeroy, & Langhorne, 2007).

Available data on stroke subtypes have been based on pathological lesions which does not offer any information about the functional status of survivors. The care of stroke survivors has provided the need to measure health outcomes associated with stroke rehabilitation. Studies have shown that measurement of functional outcome of stroke survivors is important in developing good treatment goals and identifying poor prognosis in stroke survivors (Lin, Hsieh, Lo, Hsiao, & Huang, 2003). Identifying functional subtypes of stroke among acute stroke patients is an important research priority. To the researcher’s knowledge, no study has classified stroke patients into subgroups based on functional performance outcomes. This study will identify subgroups of stroke survivors using functional performance scores.

Significance of study

Stroke rehabilitation is key when it comes to post stroke treatment and has a pivotal role in aiming to reduce the disabling effect of stroke and optimizing functional recovery of stroke survivors (Brewer, Horgan, Hickey, & William, 2013). Even though, the physical manifestations of stroke vary from person to person, studies show that functional recovery is predictable in the first few days after stroke (Nijland, van Wegen, Harmeling-van der Wel, Kwakkel, & EPOS investigators, 2013). Identifying functional subtypes among stroke survivors will help physiotherapists to effectively predict prognosis and develop target plans and treatments to successfully reduce the functional deficits experienced by stroke survivors. Data that will be obtained from this study may inform the design of future stroke rehabilitation research in Ghana.

The aim of the study is to identify stroke subtypes based on functional performance in stroke survivors receiving treatment at two tertiary hospitals in Accra.

Objectives

• To describe the demographic and clinical characteristics of stroke survivors receiving treatment at two tertiary hospitals in Accra.
• To compare functional performance scores between male and female stroke survivors.
• To categorise patients into specified subtypes of stroke using functional performance scores

​Definition and classification of stroke

According to the World Health Organization (WHO), “stroke is the rapidly developing clinical signs of focal (or global cases of coma) disturbances of cerebral functions, with symptoms lasting 24 hours or longer, or leading to death, with no apparent cause other than that of vascular origin” (Hatano, 1976). Stroke is broadly classified into two major categories: ischaemic stroke and haemorrhagic stroke. Haemorrhagic stroke is caused mainly due to spontaneous rupture of blood vessels or aneurysms whiles ischaemic stroke has to do with the occlusion of cerebral artery (Warlow, Dennis, Wardlaw, & Sandercock, 2003). Ischaemic stroke is globally considered as the most common with it representing about 85% of cases and haemorrhagic being 15% (Musuka, Wilton, Traboulsi, & Hill, 2015) but in Ghana, there are more cases of haemorrhagic stroke as compared to ischaemic stroke cases (Wiredu & Nyame, 2001)

Burden of stroke

Stroke is the second leading cause of death globally with an estimated annual mortality rate of 5. 5 million (Lopez, Mathers, Ezzati, Jamison, & Murray, 2006) . According to WHO, stroke is the third leading cause of adult disability worldwide, which means the burden of stroke also lies in high morbidity as 50% of survivors are chronically disabled (Marsh & Keyrouz, 2010). In Ghana, stroke is ranked among the top three causes of mortality and one of the most relevant cause of disability (Wiredu & Nyame, 2001). Stroke is fast becoming the leading reason for hospital admissions in Ghana (Agyeman, et al. , 2010) and causes high level of disability which poses a huge burden on stroke survivors ,their families, healthcare services and the whole society (Ouyang, et al. , 2018). The effects of stroke on the elderly, young people and poor communities are uneven and further drags individuals and households into poverty as well as drains the government’s health care budget (Aikins, 2007). The economic implication of stroke is huge, as 48% of stroke patients are below 65 years of age and may have a negative economical implication on the health care system and the loss of income and productivity of the affected individuals either directly through the disease or indirectly as caregivers to those with stroke (Agyeman, et al. , 2012).

Current classications (Subtypes) Of stroke

Physical manifestation of stroke is very diverse with more than 150 known causes (Amarenco, Bogousslavsky, Caplan, Donnan, & Hennerici, 2009). The difference between the two broadly classified types of stroke; ischaemic and haemorrhagic stroke is significant for stroke management and treatment decisions. Haemorrhagic is subdivided into intracerebral, which contributes to 10% of the 13% of all haemorrhagic stroke and subarachnoid haemorrhage which contributes to 3% in United States (Yamanda, et al. , 2018). However, for ischaemic stroke there are various systems for subtyping among which includes Stroke Data Bank subtype system, Oxfordshire Community Stroke Project subtype system and the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) subtype system (Amarenco, Bogousslavsky, Caplan, Donnan, & Hennerici, 2009) which focuses mainly on pathological lesions. Recovery from stroke varies from patient to patient in terms of outcome and estimates provides that 25%-74% of the 50 million stroke survivors worldwide needs some form of assistance or are fully dependent on caregivers for ADL post-stroke (Miller, et al. , 2010). In a study conducted by Kelly, et al. (2003) patients with intracerebral haemorrhage had more functional deficits than cerebral infarction and made greater gains in rehabilitation and hence intracerebral haemorrhagic patients especially those with a supratentorial intracerebral haemorrhage should be identified for early rehabilitation. In a Brazilian-Spanish cross-sectional study conducted on stroke subtypes and comorbidity among ischaemic stroke patients, cardioembolic and atherothrombotic had the poorest functional recovery whiles lacunar stroke patients had a better functional recovery (Carod-Artal, et al. , 2014). Also, George, et al. (2000) in a population-based study of functional outcome, survival and recurrence associated with lacunar stroke had the best functional outcome with more than 80% of patients having minimal or no impairment after 1 year and patients with cardioembolic stroke had the worst long-term survival rate. In a North East Melbourne Stroke Incidence study on handicap after stroke, of all the types of cerebral infarcted stroke, total anterior cerebral infarction (TACI) had the most disability and those with lacunar infarction (LACI) were the least disabled type at 3 and 12 months after stroke (Sturm, et al. , 2002).

A further subdivision of stroke based on functional profiles of stroke survivors is of vital importance in the clinical setting since subtypes on the basis of the side of lesion is not enough to predict functional outcomes.

Study design and methods

Study design

The study will be a cross-sectional survey.

Study sites

The study will be conducted at the Stroke units of Greater Accra Regional hospital and Korle Bu Teaching Hospital.

Participants

Participants for this study will be stroke survivors admitted to stroke units in the two tertiary hospitals in Accra.

Sampling technique

A convenience sampling method will be employed.

Inclusion criteria

• Patients who are 20-70 years of age.
• First stroke attack.
• Patient should be medically stable i. e. good vitals (good SPO2 and pulse, controlled BP)

Exclusion criteria

• History of previous stroke attack
• Any other condition which may cause disability, functional and cognitive impairment which will hinder assessment procedure.
• Patients who are unwilling to partake in the study.

Sample size calculation

Using Yamane’s formula, n=N/1+Ne² where n is the minimum sample size

N= population size (204)

e= margin of error (%) = 0. 05

Thus n=204/1+(204*0. 05²) = 135

Therefore, minimum sample size is 135

Instruments and materials

Functional independence measure (FIM) will be used to assess the functional level of the stroke survivors. FIM assess a person’s level of functional independence to carry out ADL safely and autonomously. The 18 items on the FIM assess the degree of disability and burden of care (Chumney, et al. , 2010). Thirteen items define disability in motor function and five disability in cognitive functions (Stineman, et al. , 1996). The reliability of FIM has a Cronbach alpha on admission of 0. 88 and on discharge of 0. 91 (Hsueh, Lin, Jeng, & Hsieh, 2002). FIM is the basic indicator of a patient’s functional outcome.

Barthel Index (BI) is a simple tool that measures disability or dependence in activities of daily living in stroke ( (Collin, Wade D, S, & Home, 1988). The BI was developed in 1965 (Mahoney & Barthel, 1965) and later modified by Granger and co-workers (Granger, Devis, Peters, Sherwood, & Barrett, 1979) as a scoring technique that measures the patient’s performance in 10 activities of daily life. The BI is considered a reliable disability scale for stroke patients (D’Olhaberriague, Litvan, Mitsias, & Mansbach,, 1996). The items can be divided into a group that is related to self-care (feeding, grooming, bathing, dressing, bowel and bladder care, and toilet use) and a group related to mobility (ambulation, transfers, and stair climbing).

The FIM and BI will not be hosted online but printed out and administered to patients.

A self-designed data capturing form hosted online (google form) will be used to obtained demographic and clinical data.

Procedure for data collection

Participants for this study will sign a written informed consent upon detailed explanation of the significance of the study after the study is approved by the Ethics and Protocol Review Committee of the School of Biomedical and Allied Health Sciences, University of Ghana.

FIM and BI will be administered to patients within 78 hours after admission and the scores will be entered into the google form. Clinical and Demographic data will be obtained from patient’s folder and entered into the google form. Data will be collected within 3 months.

Data management plan

The recorded data will be kept safe on a password protected computer until the entire data collection is completed and the results are analysed.

Data analysis

• Descriptive analysis will be conducted using the statistical Package for Social Sciences (SPSS) for windows, version 23. 0.
• Descriptive analysis such as mean, frequency and standard deviation will be used to summarise demographic and clinical data.
• Independent t-test will be used to compare functional performance between male and female stroke survivors.
• To identify subtypes based on functional ability profile, K-means cluster analysis will be performed.

Ethics

Approval will be sought out from Ethics and Protocol Review Committee of school of Biomedical and Allied Health Sciences, University of Ghana as well as heads of each of the stroke units of selected hospitals. A written consent will be sought from all participants after a detailed explanation on what the study is about, possible benefits and as well as their roles which will be made available through an information sheet. Participants will only take part in the study at their own will and no participant will be forced into taking part in the study. Participants who initially agreed to take part in the study after consenting can withdraw from the study at any point for whatever reasons they have without any consequence. Information obtained from the study will be kept confidential and participant’s anonymity will ensue throughout data collection and analysis. All data obtained will only be used for the purpose of this study alone.