Noor Azah Aziz

Function and quality of life following stroke rehabilitation: have our stroke patients gained optimum recovery?

Materials and methods This was a cross-sectional study of 91 stroke patients; mean age 58.9±10.6 years, 79% male, median stroke duration 13 months who have completed intensive individual rehabilitation at the Universiti Kebangsaan Malaysia Medical Centre in the years 2010 and 2011. Rehabilitation outcome was measured with the use of standardised tools; Rivermead Mobility Scale (RMI), Berg’s Balance Scale (BBS), Sit to Stand Test (STS) for lower limb strength and Timed 10 metre walk test for walking speed. Post-rehabilitation disability level and quality of life were also assessed on a Modified Rankin Scale (mRS) and Euro-Qol 5 Dimensions-Visual analogue Scale (EQ5D-VAS), respectively. All data were analysed descriptively using SPSS version 18.

Exploring views on long term rehabilitation for people with stroke in a developing country: findings from focus group discussions

BackgroundThe importance of long term rehabilitation for people with stroke is increasingly evident, yet it is not known whether such services can be materialised in countries with limited community resources. In this study, we explored the perception of rehabilitation professionals and people with stroke towards long term stroke rehabilitation services and potential approaches to enable provision of these services. Views from providers and users are important in ensuring whatever strategies developed for long term stroke rehabilitations are feasible and acceptable.MethodsFocus group discussions were conducted involving 15 rehabilitation professionals and eight long term stroke survivors. All recorded conversations were transcribed verbatim and analysed using the principles of qualitative research.ResultsBoth groups agreed that people with stroke may benefit from more rehabilitation compared to the amount of rehabilitation services presently provided. Views regarding the unavailability of long term rehabilitation services due to multi-factorial barriers were recognised. The groups also highlighted the urgent need for the establishment of community-based stroke rehabilitation centres. Family-assisted home therapy was viewed as a potential approach to continued rehabilitation for long term stroke survivors, given careful planning to overcome several family-related issues.ConclusionsBarriers to the provision of long term stroke rehabilitation services are multi-factorial. Establishment of community-based stroke rehabilitation centres and training family members to conduct home-based therapy are two potential strategies to enable the continuation of rehabilitation for long term stroke survivors.

Early Dementia Questionnaire (EDQ): A new screening instrument for early dementia in primary care practice

BackgroundWorldwide, the population is ageing, resulting in an associated increase in dementia prevalence. Forgetfulness in elderly people is often perceived as normal in some local cultures and thus, the early detection of dementia in primary care requires detection of symptoms other than memory complaints.This study was conducted to screen elderly patients for early dementia in primary care using a newly developed Early Dementia Questionnaire (EDQ) and comparing it with a standard assessment tool, the Mini Mental State Examination (MMSE).MethodsA cross-sectional study was conducted on a group of elderly patients using convenience sampling of consecutive patients. Elderly depression was excluded using the Geriatric Depression Scale (GDS). Exclusion criteria also included known cases of dementia. Inclusion criteria included a score of 5 or less in GDS and the presence of a reliable informant. A face-to-face interview was done using the EDQ with the patient and informant to elicit symptoms of early dementia. If the informant was not present, a telephone interview was used instead. The patient was then assessed with the Mini Mental State Examination (MMSE) using a cut-off point of 21.ResultsPrevalence of dementia among 155 subjects was 52.3% by EDQ and 15.5% by MMSE. The EDQ demonstrated a sensitivity of 79.2% with specificity of 52.7%. Positive predictive value (PPV) of EDQ was 23.5% with the negative predictive value (NPV) of 93.2%. The strongest predictor of possible early dementia was complaints of memory problems (OR 26.22; 95% CI 2.03–338.14) followed by complaints of concentration problems (OR 14.33; 95% CI 5.53–37.12), emotional problems (OR 4.75; 95% CI 1.64–13.81) and sleep disturbances (OR 3.14; 95% CI 1.15-8.56). Socio-demographic factors, medical problems and smoking status were not associated with possible dementia (p>0.05), despite that 60–70% of the elderly had chronic illnesses.ConclusionThe EDQ is a promising alternative to MMSE for screening of early dementia in primary care.

The integrated care pathway for post stroke patients (iCaPPS): a shared care approach between stakeholders in areas with limited access to specialist stroke care services

BackgroundLack of intersectoral collaboration within public health sectors compound efforts to promote effective multidisciplinary post stroke care after discharge following acute phase. A coordinated, primary care-led care pathway to manage post stroke patients residing at home in the community was designed by an expert panel of specialist stroke care providers to help overcome fragmented post stroke care in areas where access is limited or lacking.MethodsExpert panel discussions comprising Family Medicine Specialists, Neurologists, Rehabilitation Physicians and Therapists, and Nurse Managers from Ministry of Health and acadaemia were conducted. In Phase One, experts chartered current care processes in public healthcare facilities, from acute stroke till discharge and also patients who presented late with stroke symptoms to public primary care health centres. In Phase Two, modified Delphi technique was employed to obtain consensus on recommendations, based on current evidence and best care practices. Care algorithms were designed around existing work schedules at public health centres.ResultsIndication for patients eligible for monitoring by primary care at public health centres were identified. Gaps in transfer of care occurred either at post discharge from acute care or primary care patients diagnosed at or beyond subacute phase at health centres. Essential information required during transfer of care from tertiary care to primary care providers was identified. Care algorithms including appropriate tools were summarised to guide primary care teams to identify patients requiring further multidisciplinary interventions. Shared care approaches with Specialist Stroke care team were outlined. Components of the iCaPPS were developed simultaneously: (i) iCaPPS-Rehab© for rehabilitation of stroke patients at community level (ii) iCaPPS-Swallow© guided the primary care team to screen and manage stroke related swallowing problems.ConclusionCoordinated post stroke care monitoring service for patients at community level is achievable using the iCaPPS and its components as a guide. The iCaPPS may be used for post stroke care monitoring of patients in similar fragmented healthcare delivery systems or areas with limited access to specialist stroke care services.Trial registrationNo.: ACTRN12616001322426 (Registration Date: 21st September 2016).

Can virtual reality balance games enhance activities of daily living among stroke survivors

Background Stroke survivors with residual physical disabilities are reported to have decreased muscle strength and balance. Balance ability is one of the prerequisite for performing activities of daily living independently. Virtual reality balance games performed in the community based rehabilitation settings may be beneficial for stroke survivors to improve their functional balance resulting in increased independence in activities of daily living. The aim of this study was to evaluate the use of virtual reality balance games in improving activities of daily living among stroke survivors.

What is next after transfer of care from hospital to home for stroke patients? Evaluation of a community stroke care service based in a primary care clinic

Context: Poststroke care in developing countries is inundated with poor concordance and scarce specialist stroke care providers. A primary care-driven health service is an option to ensure optimal care to poststroke patients residing at home in the community. Aims: We assessed outcomes of a pilot long-term stroke care clinic which combined secondary prevention and rehabilitation at community level. Settings and Design: A prospective observational study of stroke patients treated between 2008 and 2010 at a primary care teaching facility. Subjects and Methods: Analysis of patients was done at initial contact and at 1-year post treatment. Clinical outcomes included stroke risk factor(s) control, depression according to Patient Health Questionnaire (PHQ9), and level of independence using Barthel Index (BI). Statistical Analysis Used: Differences in means between baseline and post treatment were compared using paired t-tests or Wilcoxon-signed rank test. Significance level was set at 0.05. Results: Ninety-one patients were analyzed. Their mean age was 62.9 [standard deviation (SD) 10.9] years, mean stroke episodes were 1.30 (SD 0.5). The median interval between acute stroke and first contact with the clinic 4.0 (interquartile range 9.0) months. Mean systolic blood pressure decreased by 9.7 mmHg (t = 2.79, P = 0.007), while mean diastolic blood pressure remained unchanged at 80mmHg (z = 1.87, P = 0.06). Neurorehabilitation treatment was given to 84.6% of the patients. Median BI increased from 81 (range: 2−100) to 90.5 (range: 27−100) (Z = 2.34, P = 0.01). Median PHQ9 scores decreased from 4.0 (range: 0−22) to 3.0 (range: 0−19) though the change was not significant (Z= −0.744, P = 0.457). Conclusions: Primary care-driven long-term stroke care services yield favorable outcomes for blood pressure control and functional level.

Identifying post stroke patients in the Malaysian community: Profile of patients managed at ten selected public health centres in Peninsular Malaysia

Materials and methods Practice registry lists at ten public health centres were screened for patients with cerebrovascular accident (CVA) between July and December 2012. Patients aged ≥18 years with recorded diagnosis of CVA either radiographically or by referring physician were recruited. Patients with transient ischaemic attack, traumatic brain injury or isolated nerve palsies were excluded. Details of stroke risk factors and clinical findings at first primary care visit were extracted from case notes and from patient/and carer interviews. Data were analysed for mean, median and proportions.

Promoting seamless transfer-of-care for stroke patients in primary care: development of the integrated care pathway for post stroke services

Background Post-stroke care after hospital discharge suffers from lack of intersectoral collaboration within the public health sectors. Hence, primary care remains the only option in managing stroke patients in underserved areas in Malaysia. This study aimed to identify the areas, which can be better coordinated to deliver optimal poststroke care in community setting. A seamless transfer of care model known as integrated Care Pathway for Post Stroke patients (iCaPPS) was designed to address this issue.

Neuropsychiatric manifestation after a stroke: newly developed symptoms or side-effect of drug?

A 55-year-old woman presented with sudden onset of left-sided body weakness and numbness, which was diagnosed as multifocal cerebral infarct with right thalamic bleed. She had concurrent hypertension, diabetes mellitus and chronic kidney disease. She suffered from central poststroke pain and reactive depression as poststroke complications, for which amitriptyline was prescribed. Unfortunately, she developed symptoms suggestive of mania and psychosis upon initiation of medications, which resolved upon withdrawal of amitriptyline. Amitriptyline is effective for treatment of poststroke pain and particularly useful in concomitant depression. Unexpectedly, this patient developed new psychopathologies after initiation of this medication. This case highlights the development of new psychopathologies that could be due to the antidepressant, underlying bipolar disorder or a complication of the stroke itself. Primary care providers need to actively enquire regarding neuropsychiatric symptoms because they can adversely affect the patients quality of life as well as impede rehabilitation efforts.

Home-based carer-assisted therapy for people with stroke: findings from a randomised controlled trial

Materials and methods A single-blinded randomised controlled trial was conducted on 91 stroke patients. In all, 76.5% males with mean age of 58.9±10.6 years and median stroke duration of 13.0 months (range 6-84) completed intensive rehabilitation at a tertiary hospital. The control group received outpatient group exercise led by therapists while the experimental group was assigned to a home-based familyassisted task-oriented training. Primary outcomes were mobility (Rivermead Mobility Scale), balance (Berg’s Balance Scale), lower limb strength (5-Times-Sit-to-Stand Test) and gait speed. Secondary outcome was healthrelated quality of life as measured using EQ5D-Visual analogue Scale. All assessments were carried out at baseline and at week twelve of intervention. An intention-totreat analysis was used to evaluate outcome of the interventions.