Title : Functional Independence of Patients at Three Months after Ischaemic Stroke

 

Functional Independence of Patients at Three Months after Ischaemic Stroke

 

 

Abstract

 

Cerebrovascular diseases rank as the second leading cause of death and disabilities. The present study was undertaken to assess the functional independence of patients at three months after ischaemic stroke and to look into its predictors. The study had a cross-sectional survey design. After institutional ethics committee permission, 40 subjects who met the inclusion criteria were recruited consecutively from the stroke registry. The subjects were assessed with a semi structured interview schedule for baseline socio-demographic and clinical data. Current neurological deficits were assessed using Na-tional Institutes of Health Stoke Scale (NIHSS) and current functional disability was assessed using modified Rankins scale (mRS), functional independence was assessed with Barthel index at three months during follow-up visit to stroke clinic. The mean age at presentation of stroke was found to be 60.2. Even though 33.3 percent of the subjects presented within 4.5 hours of experience of first symp-toms, only 10 percent were treated with thrombolytic therapy. Most of the patients were discharged and had a primary care giver. The mean admission NIHSS and mRS scores were 9.7 and 3.2 but at three months follow-up it became significantly changed to 3.7 and 2.4 respectively. The mean Barthel index score at three months was 14.1 which denoted their partial dependence on others for activities of daily living. There was no difference in functional independence between age groups or sex groups. To conclude, the degree of neurologic disability at admission was found to be a predictor of functional independence at three months.

 

Cerebrovascular diseases rank as the second leading cause of death after ischaemic heart disease. Stroke is the leading cause of death and disabilities in developing and developed countries. The demographic transition and life style changes have created highest incidence and prevalence of stroke in India including Kerala. The prevalence of stroke in India shows a wide variation of 147-922/100,000 across diverse community-based studies (Bonita & Beaglehold, 2007; Pandian et al, 2007; Prasad et al, 2012). 

According to the India stroke factsheet, the esti-mated age-adjusted prevalence rate for stroke ranges between 84/100,000 and 262/100,000 in rural and between 334/100,000 and 424/100,000 in urban ar-eas (Stroke Fact Sheet, 2013). 

 

In Thiruvananthapuram, the occurrence of stroke rate of 7.1 per 1000 per year in people aged 55 years or above, and the rate escalated to 13.3 in people aged 75 years or above (age-adjusted). The stroke in the young age group defined as 40 years or less comprised 3.8 percent (Sridharan et al, 2009). The types and degrees of disability that follow a stroke depend upon which area of the brain is damaged and amount of damage. Rehabilitation helps stroke survivors re-learn skills that are lost when part of the brain is damaged. For example, these skills can include coordinating leg movements in order to walk or carrying out the steps involved in any complex activity. Rehabilitation also teaches survivors new ways of performing tasks to circumvent or compensate for any residual disabilities. 

Nurses specialising in rehabilitation help survivors relearn how to carry out the basic activities of daily living such as bathing and controlling inconti-nence. Most stroke survivors regain their ability to maintain continence, often with the help of strategies learned during rehabilitation. For some stroke survivors, rehabilitation will be an ongoing process to maintain and refine skills and could involve working with specialists for months or years after the stroke.

Majority of stroke survivors continue to live with dis-abilities, and the costs of on-going rehabilitation and long term-care are largely borne by family members.

The present study attempted to find out the func-tional independence of patients at three months after ischemic stroke and to look into the predictors of functional independence after stroke.

Review of literature

A study on factors predictive of stroke outcome in a rehabilitation setting found that age and severity of deficit were most reliable for patients at either extreme of the disability spectrum. Outcome was analysed in terms of functional improvement and disposition. Patients younger than 55 years or with an admission Functional Independence Measure (FIM) greater than 80 almost universally went home. Admission FIMs less than 40 were associated with nearly certain nursing home discharge. The com-prehensive FIM score was a stronger predictor of outcome than motor impairment in isolation. An admission FIM of 60 or more was associated with a higher probability of functional improvement during rehabilitation. Small-vessel strokes had the best outcome. Intracerebral haemorrhages improved more than ischaemic strokes but more slowly. Right hemisphere lesions did worse than left. Comorbidities influenced outcome only when several conditions accumulated (Ween et al, 1996).

KC Johnston et al (2013), in a study to determine the multivariable relationship between infarct volume, clinical variables, and 3-month outcomes in ischaemic stroke patients found that combined clinical and imaging variables are predictive of 3-month outcome in ischaemic stroke patients.

Under Trivandrum stroke registry, among the total 541 patients registered during the 6 months study period, the mortality data show that 147 patients did not survive beyond the 28th post-stroke day, fatality rate being 27.2 percent (24.5% for urban and 37.1% for rural population, p=0.011; 106 (72.1%) of these deaths occurred within 10 days of stroke onset (Sridharan et al, 2009). Of the 394 patients who survived beyond the 28th day of stroke onset, functional outcome was available in 342 (86.8%) patients. Mild disability (Rankins scorewas observed in 145 (42.4%) of them. Whereas 50 (14.6%) patients were bedridden (Rankins score 5), 147 (43%) were moderately disabled (Rankins score 3 or 4). There was no significant difference in the functional outcome between males and females (p=0.179), between urban and rural patients (p=0.515), or across different age groups (p=0.526).

In a community-based study to assess handicap 3 and 12 months after first-ever stroke, of surviving patients, 113 (59%) were assessed at 3 months and 107 (64%) at 12 months. The domains of handicap most affected were physical independence and occupation. Only half the variance in handicap was due to disability. Of patients without disability, those who claimed complete recovery were less handicapped than those who claimed incomplete recovery. Patients with total anterior circulation infarction were more handicapped at 3 and 12 months than those with other subtypes of cerebral infarction (Sturm et al, 2009).

In 150 prospectively studied stroke patients consecutively admitted to the inpatient rehabilitation department, functional ability was assessed with the FIM instrument on admission, on discharge of in-patient rehabilitation programme, and at the 6 months follow-up visit after discharge. Severity of stroke was determined by using the Canadian Neurological Scale (CNS) on admission. Of the 142 subjects surveyed, 23 (16.2%) stroke patients achieved functional independence at home when revisited. The study found that the admission CNS and FIM scores are useful in the prediction of functional independence for stroke survivors following rehabilitation therapy.

Objectives

The objectives of the study were: (i) to identify the func-tional independence of patients at three months after ischaemic stroke; (ii) to find out the relationship between functional independence and predicted variables.

Predicted variables were age, sex, comorbid conditions, NIHSS score during acute stroke, physiotherapy status, door to needle time, time taken to reach hospital after experiencing first symptom, current deficits and presence of dedicated primary care giver.

Methodology

In this quantitative cross-sectional survey type study, the tools and technique followed were as under:

Barthel index was used to assess the functional in-dependence. NIHSS was used to assess the current neurological deficits. Modified Rankins scale was used to assess the functional disabilities. Semistructured interview schedule was employed to assess the basic clinical and sociodemographic data technique use involved interview and observation. Post-ischaemic stroke patients on follow-up visit to stroke clinic was three months. Sample size was 40.

 

Inclusion criteria: Patients on three months follow-up in stroke clinic after ischemic stroke. There was no history of stroke or functionally independent before stroke.

 

Exclusion criteria: Patients who are not willing to par-ticipate; Minor strokes or NIHSS<3.

The setting of the study was Stroke clinic at SCTIMST, Thiruvananthapuram.

 

Data collection process: Permission was obtained from technical advisory committee and institute’s ethics committee. The researcher recruited those who met the inclusion criteria through consecutive sampling technique from the stroke registry. The subjects were assessed by observation and interview at three months during follow-up visit to stroke clinic by the researcher herself. In case of aphasic patients the care givers were interviewed. Informed consent was obtained from those who met the inclusion criteria. Baseline sociodemographic and clinical data were collected us-ing a semi structured interview schedule. Neurologi-cal deficit was assessed using NIHSS and current func-tional disability using modified Rankins scale (mRS). The functional independence was assessed using Barthel index. Data was analysed using SPSS.17.0.

 

Results

Distribution of subjects according to baseline socio-demographic and clinical data: 36.7 percent of subjects were female and 63.7 percent were male. The mean age of presentation was 60.67 (SD 13.12); 53.3 per-cent of subjects were diabetic; 66.7 percent were hypertensive; 33.3 percent of subjects were having right middle cerebral artery stroke; 26.7 percent were having left middle cerebral artery stroke and 23.3 percent were having vertebrobasilar artery stroke; 90 percent were atherosclerotic and remaining were cardioembolic. A third (33.3%) reached hospital be-fore 4.5 hrs of onset of symptoms. 83.3 percent were managed conservatively. The mean admission mRS was 3.7. Average Admission NIHSS was 9.1 and 96.7 percent of subjects were discharged to home; 76.7 percent were continuing physiotherapy at home; 93.3 percent of subjects were having dedicated primary care giver (Table 1).

Functional independence at three months: The Barthel index at three months was 14.1 5.3. The mRS score at three months was 2.4 1.4. The average NIHSS score at three months was 3.7 3.6 (Table 2).

The common deficits observed at three months were upper and lower extremity weakness, dysar-thria, sensory disturbances and bowel and bladder dysfunctions.

 

Predictors of functional independence at three months: age, sex, admission mRS, co morbid conditions, type of stroke, time taken to reach the hospital, man-agement done, presence of primary care giver, dis-charge destination and physiotherapy status were assessed for their relationship with functional in-dependence at three months but statistically sig-nificant association could not be obtained. Admis-sion NIHSS score was found to be significantly re-lated to functional independence at three months with p>0.008 (Table 3).

 

Discussion

In present study, investigating the functional inde-pendence of patients at three months after ischaemic stroke, the Barthel index was 14.1 5.3. This shows that at three months the ischaemic stroke patients need minimal help for activities of daily living and were partially independent. The mRS score at three months was 2.4 1.4 which corresponds to minimal physical disability. The average NIHSS score at three months was 3.7 3.6 which is equal to a very mild stroke status of neurological disability. Admission NIHSS score was found to be significantly related to functional independence at three months (p>0.008). Patients were continuing physiotherapy and most of the patients, primary care giver was there and were cared in home, after discharge from hospitals.

The hypothesis of the study was found to be true and accepted. Objectives of the study were met. Dif-ferent studies have been conducted to find out the factors predictive of functional independence after stroke. According to Trivandrun stroke registry, among the 342 patients who survived beyond the 28th day of stroke onset, Mild disability (Rankin score 2) was ob-served in 145 of them. There was no significant dif-ference in the functional outcome between males and females (p=0.179), between urban and rural patients (p=0.515), or across different age groups (p=0.526).

A study on multivariable relationship between infarct volume, clinical variables, and 3-month out-comes in ischemic stroke patients found that com-bined clinical and imaging variables were predictive of 3-month outcome in ischaemic stroke patients. The variables assessed were prior stroke disability and diabetes, infarct volume, small vessel and ini-tial NIHSS.

Recommendations 

In the light of above study the following recommen-dations are put forward: Follow up studies to find out the functional independence at later periods; Factors contributing to delay in hospitalisation; Compliance with secondary prevention strategies; and Interventional studies to assess the effect on functional independence.

Conclusion

Ischaemic stroke leads to physical, neurological and functional disability. At three months, ischaemic stroke patients needed minimal help with activities of daily living and were partially independent and were having minimal physical disability. Their neurological disability was very mild. The degree of neurologic disability at admission was found to be a predictor of functional independence at three months. Thus, early detection of warning signs of stroke and initiation of treatment can lead to less neurological damage and better functional recovery. In addition, stroke preventive services has to be meticulously implemented.

 

References

 

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Author: Shani SD

Staff Nurse, SCTIMST, Thiruvananthapuram (Kerala)

Source: TNAI Journal