|Year : 2016 | Volume
| Issue : 3 | Page : 63-68
Health-related quality of life among postischemic stroke patients
Salman Mansoor1, Maimoona Siddiqui1, Salman Assad2, Sehrish Javed3, Nadia Mehboob1, Anam Abrar1, Nabeel Muzaffar Syed1, Memoona Nasir1, Qamar Zaman1, Hamza Hassan Khan2, Ahmed Shah Bukhari1
1 Department of Neurology, Shifa International Hospital, Islamabad, Pakistan
2 Department of Neurology, Shifa College of Medicine, Islamabad, Pakistan
3 Atta-ur-Rahman School of Applied Bioscience, National University of Science and Technology, Islamabad, Pakistan
|Date of Submission||30-Jul-2016|
|Date of Acceptance||02-Sep-2016|
|Date of Web Publication||30-Sep-2016|
Department of Neurology, Shifa International Hospital, Islamabad
Source of Support: None, Conflict of Interest: None
Aim: This study aims to assess the effects of health-related quality of life (HRQOL) in postischemic stroke patients. Methods: The cross-sectional survey included 100 patients who presented at neurology outpatient clinic of Shifa International Hospital of Pakistan for follow-up 6 months after stroke. The Short Form Health Survey (SF-36) was used to assess HRQOL. Stroke severity was determined by the National Institute of Health Stroke Scale. The modified Rankin scale (mRS) was used to assess functional status and outcome. Results: Totally 100 patients including 63% males and 37% females with a mean age of 60.18 13.1 years participated in this study. Among 41 (41%) patients with mRS ≥3, there were 22 (54%) males and 19 (46%) females as compared to 59 (59%) patients with mRS R3 including 41 (70%) males and 18 (31%) females. There were 57% of patients presented with right-sided weakness, 37% with left-sided weakness, 3% exhibited speech difficulty, and 1% presented with visual problems. Nonhypertensive patients scored better in physical role domain as compared to hypertensive patients (P = 0.004) on SF-36. Better social functioning was observed in those who had ischemic heart disease as compared to those without disease (P < 0.001). Higher physical component scores were seen among dyslipidemics as compared to nondyslipidemic patients (P = 0.052). Conclusion: This study provides insight into the relation between several health domains and major diseases in poststroke patients. This information is very important for physicians to rehabilitate poststroke patients presenting with comorbidities.
Keywords: Comorbidities, dyslipidemia, health-related quality of life, hypertension, postischemic stroke
|How to cite this article:|
Mansoor S, Siddiqui M, Assad S, Javed S, Mehboob N, Abrar A, Syed NM, Nasir M, Zaman Q, Khan HH, Bukhari AS. Health-related quality of life among postischemic stroke patients. Transl Surg 2016;1:63-8
|How to cite this URL:|
Mansoor S, Siddiqui M, Assad S, Javed S, Mehboob N, Abrar A, Syed NM, Nasir M, Zaman Q, Khan HH, Bukhari AS. Health-related quality of life among postischemic stroke patients. Transl Surg [serial online] 2016 [cited 2019 Jun 24];1:63-8. Available from: http://www.translsurg.com/text.asp?2016/1/3/63/191483
| Introduction|| |
Stroke is a serious problem which not only deprives its sufferer of normal life activities but also negatively impacts the life of caregivers.  Focus is presently being diverted to finding effective strategies for rehabilitation and ensuring good quality of life (QOL) in poststroke patients rather than to finding cure and prevention.  Pakistan is one of the lower-income countries, and the burden of stroke is more in lower- and middle-income countries as compared to higher income countries where substantial decrease in the incidence of stroke has been reported. ,, According to one community-based study, the prevalence of stroke in Pakistan is 218,100,000.  Stroke is the leading cause of long-term functional and cognitive disabilities in patients and thus badly influences their physical, psychological, and social wellbeing.  These changes in life directly affect health-related QOL (HRQOL) of the stroke survivors. , HRQOL provides a self-analyzing multidimensional measuring scale with respect to physical, mental, and social health. , Stroke patients report a decrease in QOL.  QOL has been defined as an individual's own perception of the degree to which a disease has affected his/her life.  It is important to understand the manifestation of a disease and its recovery from the patients' perspective so as to formulate adequate strategies to improve their lives.  This area in stroke care has never gained sufficient attention and has been neglected in many parts of the world, especially in developing countries. There are limited data on the QOL in the early poststroke phase and the changes in it over time.  The unique regional culture of Pakistan may impose a different effect on QOL as previously known from the studies of other regions. Moreover, the high prevalence of several diseases, such as dyslipidemia, hypertension, or diabetes may act as potential risk factor for the occurrence of stroke. , It indicates that these diseases in poststroke patients may adversely affect their QOL. Therefore, it is very important for clinicians and caregivers to have an adequate estimation of the correlation between major diseases and factors specific to the region and QOL of poststroke patient to take appropriate measures. Thus, the objective of this study is to compare the HRQOL and comorbidities in stroke survivors after 6 months.
| Methods|| |
We conducted a cross-sectional survey based on nonprobability convenience sampling that included 100 patients seen between December 2014 and December 2015 at outpatient neurology department for follow-up 6 months after a stroke. Informed consent was given either by the patients themselves or their family members. All the ethical parameters were observed, and their confidentiality was ensured after the approval from an institutional review board of Shifa International Hospital of Pakistan. Stroke patients were characterized depending on the type of the stroke they had, i.e., left hemisphere stroke, right hemisphere stroke, ischemic stroke, hemorrhagic stroke, etc., Stroke outcomes were assessed using the modified Rankin scale (mRS) [Table 1]. Hemorrhagic stroke patients were excluded from this study. All ischemic stroke patients were included irrespective of their age, ethnic group, and gender and comorbidities. All those patients who were either already diagnosed or diagnosed at the time of their admission in hospital for diabetes mellitus, hypertension, atrial fibrillation, ischemic heart disease, and dyslipidemia irrespective of their chronicity were included in this study.
The Short Form Health Survey (SF-36) is commonly used with high validity and sensitivity for group-based studies [Figure 1].  The SF-36 questions were translated into local Urdu language, and those questions were asked to 18 postischemic stroke patients who were not added to the current study. This was first done to ensure that participants in the study could understand each question easily and that back translation of questions from Urdu to English language would be successful.
The questions on the HRQOL questionnaire were easy to understand and acceptable for the respondents. The effectiveness of such questionnaire in determining the burden of many diseases such as stroke, cancer, and diabetes on life and comparison of such diseases to find a significant correlation between them have been reported in many publications.  It is based on a patient's evaluation of his or her mental and physical health functioning. For each scale on SF-36 form, a score ranging from 0 to 100 is used where 0 is for very poor, 50 for moderate and 100 is for excellent [Figure 1]. , The stroke severity in each patient was determined by the National Institute of Health Stroke Scale (NIHSS).  The mRS was used to determine the functional status. Descriptive statistics and independent sample t-test and Fischer exact test were used for data analysis using SPSS 21.0 statistical software (SPSS Inc., Chicago, IL, USA). P < 0.05 was considered statistically significant to establish correlation.
| Results|| |
Stroke patients were assessed for their QOL. A total of 100 patients, 63 (63%) males and 37 (37%) females with a mean age of 60.18 ± 13.1 years participated in the study. There were 7 (7%) patients in the young age group (0-40 years), 41 (41%) patients in the middle age group (40-60 years), and 52 (52%) patients in the older age group (≥60 years) [Table 2]. Among ischemic strokes 62 (62%) were large vessel strokes, 26 (26%) were small vessel, 5 (5%) were cardioembolic, and 1 (1%) was of undetermined etiology [Table 3]. 57 (57%) patients presented with right-sided weakness, 37 (37%) with left-sided weakness, 3 (3%) patients with speech difficulty, and 1 (1%) patient presented with visual problems as shown by the NIHSS [Table 4]. 41 (41%) patients with 22 (54%) males and 19 (46%) females had an mRS of ≥3 as compared to 59 (59%) patients with 41 (70%) males and 18 (31%) females who had an mRS of ≤3. No statistical difference was found on mRS ≥3 among patients with either left- or right-sided weakness. A total of 20/38 (52.6%) patients with left-sided weakness and 21/56 (37.5%) patients with right-sided weakness had mRS of ≥3 (P = 0.4501). Comparisons for scores of QOL in ischemic stroke patients with and without chronic conditions were done by use independent sample t-test [Table 5].
|Table 5: Differences of health - related quality of life in different chronic condition with independent sample t-test used to compute P value|
Click here to view
| Discussion|| |
We evaluated HRQOL of poststroke patients after 6 months in a sample of Pakistan population. We used the SF-36 consisting of eight scaled scores, which are the weighted sums of the questions in their section. Each scale is directly transformed into a 0-100 scale on the assumption that each question carries equal weight. Lower scores mean more disability and higher scores mean less disability. A score of 0 is equivalent to maximum disability, and a score of 100 is equivalent to no disability [Figure 1]. Components of QOL were compared on the basis of comorbidities and presence or absence of one or more chronic conditions. Patients who had no comorbidities or chronic conditions scored well in bodily pain with mean score (MS) of 75.4 and mental combined score (MS: 65.14) which owing to the low sample size (n = 10) in the group was not statistically significant when compared to those who had one or more chronic conditions. Nondiabetic patients scored well in the domain of mental health (MS: 72) as compared to diabetic patients (MS: 68). Although this difference was not statistically significant (P = 0.060). These results were in contrary to ones reported by Luitse et al.  and Suenkeler et al.,  where poststroke diabetics were associated with a poor HRQOL.
Nonhypertensive patients scored better in the domain of physical role limitation (RP) (MS: 31) as compared to hypertensive patients (MS: 14) with a statistical significance of P = 0.004. Khaw et al. used a similar SF-36 study to show a lower HRQOL in RP domain in hypertensive patients. Hypertension manifests itself in the form of headaches, blurred vision, irritability and dizziness and these factors if present with stroke can further reduce the recovery and it is a risk factor for recurrence of stroke. Cífkovα et al.  reported 91.5% ischemic poststroke patients had hypertension.
There were some unexpected results observed in people who had dyslipidemias as compared to those who did not have the condition. In role physical domain, dyslipidemic patients had an MS of 23 as compared to 10 in nondyslipidemic patients (P < 0.001). Similarly, in the physical component score, dyslipidemics had an MS of 48 as compared to 43 in nondyslipidemic patients (P = 0.052). Slightly better MSs were found in components of vitality in nondyslipidemics (MS: 55) as compared to dyslipidemics (MS: 53) (P = 0.013). A similar finding of higher HRQOL in dyslipidemics was also found in cardiac patients by Lalonde et al. where the overall MS of dyslipidemic and nondyslipidemic patients was lower than that of the MS seen in the relation of stroke with other comorbid diseases. While dyslipidemia is known to be a risk factor for the recurrence of stroke and its prevalence in Pakistan is high, our study suggested that its role in several domains of HRQOL is otherwise quite better than nondyslipidemic subjects. Better social functioning was observed in those who had ischemic heart disease as compared to those without disease (P < 0.001). Low sample size was the limiting factor in meaningful results in patients who had atrial fibrillation. However, atrial fibrillation negatively impacts HRQOL in poststroke patients, but radiofrequency ablation of the aberrant focus, rate and rhythm control strategies can improve the QOL. ,,,,
Almost half of the patients were elderly with ≥60 years of age (52%) in our study. Al-Jadid et al. and al-Rajeh et al. showed that frequency of stroke is steadily increased with age, which is consistent with our analysis. , Hopman et al. using the SF-36 form, demonstrated that increasing age along with chronic diseases have a strong negative correlation with the physical health domain while the mental domain has no relation with advancing age in the presence of chronic diseases. This is in contrast to our results where the mental quality of health is also negatively affected in the presence of some chronic diseases. A study done in Nigeria by Abubakar and Isezuo  documented that depression was present in 29% postischemic stroke patients.
In the current study, females were found to show relatively poor QOL as compared to males. A study done on Northern Chinese population showed similar results as females had worse outcomes when measured 6 months after stroke. They also used an SF-36 survey to show that females have lower MS than males. 
In conclusion, HRQOL is an important. factor among stroke survivors. There are few studies in the literature on HRQOL of stroke patients in developing nations with the exception of one study done in Nigeria that listed depression in poststroke patients. We hope that this analysis addressing the HRQOL in stroke patients among Pakistani population will open a gateway to introduce more research on this issue in developing nations. In addition, lack of generalization of results is a limitation of our study. This study was done in a low to middle-income country like Pakistan, and these results cannot be generalized to developed countries.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Godwin KM, Ostwald SK, Cron SG, Wasserman J. Long-term health-related quality of life of stroke survivors and their spousal caregivers. J Neurosci Nurs
Teasell R, Rice D, Richardson M, Campbell N, Madady M, Hussein N, Murie-Fernandez M, Page S. The next revolution in stroke care. Expert Rev Neurother
Mukherjee D, Patil CG. Epidemiology and the global burden of stroke. World Neurosurg
Thrift AG, Cadilhac DA, Thayabaranathan T, Howard G, Howard VJ, Rothwell PM, Donnan GA. Global stroke statistics. Int J Stroke
Towfighi A, Saver JL. Stroke declines from third to fourth leading cause of death in the United States: Historical perspective and challenges ahead. Stroke
Kamal AK, Itrat A, Murtaza M, Khan M, Rasheed A, Ali A, Akber A, Akber Z, Iqbal N, Shoukat S, Majeed F, Saleheen D. The burden of stroke and transient ischemic attack in Pakistan: A community-based prevalence study. BMC Neurol
Moran GM, Fletcher B, Feltham MG, Calvert M, Sackley C, Marshall T. Fatigue, psychological and cognitive impairment following transient ischaemic attack and minor stroke: A systematic review. Eur J Neurol
Dhamoon MS, Moon YP, Paik MC, Boden-Albala B, Rundek T, Sacco RL, Elkind MS. Quality of life declines after first ischemic stroke. The Northern Manhattan study. Neurology
Horner-Johnson W, Krahn G, Andresen E, Hall T; Rehabilitation Research and Training Center Expert Panel on Health Status Measurement. Developing summary scores of health-related quality of life for a population-based survey. Public Health Rep
Khanna D, Tsevat J. Health-related quality of life - An introduction. Am J Manag Care
Fulk GD, Ludwig M, Dunning K, Golden S, Boyne P, West T. How much change in the stroke impact scale-16 is important to people who have experienced a stroke? Top Stroke Rehabil
Dayapoglu N, Tan M. Quality of life in stroke patients. Neurol India
Edwards JD, Koehoorn M, Boyd LA, Levy AR. Is health-related quality of life improving after stroke? A comparison of health utilities indices among Canadians with stroke between 1996 and 2005. Stroke
Christensen MC, Mayer S, Ferran JM. Quality of life after intracerebral hemorrhage: Results of the factor seven for acute hemorrhagic stroke (FAST) trial. Stroke
Taj F, Zahid R, Syeda UE, Murtaza M, Ahmed S, Kamal AK. Risk factors of stroke in Pakistan: A dedicated stroke clinic experience. Can J Neurol Sci
Khan NI, Naz L, Mushtaq S, Rukh L, Ali S, Hussain Z. Ischemic stroke: Prevalence of modifiable risk factors in male and female patients in Pakistan. Pak J Pharm Sci
Brazier JE, Harper R, Jones NM, O′Cathain A, Thomas KJ, Usherwood T, Westlake L. Validating the SF-36 health survey questionnaire: New outcome measure for primary care. BMJ
Chang DF, Chun CA, Takeuchi DT, Shen H. SF-36 health survey: Tests of data quality, scaling assumptions, and reliability in a community sample of Chinese Americans. Med Care
Luitse MJ, Biessels GJ, Rutten GE, Kappelle LJ. Diabetes, hyperglycaemia, and acute ischaemic stroke. Lancet Neurol
Gandek BJ, Sinclair SJ, Kosinski M, Ware JE. Psychometric evaluation of the SF-36®
health survey in medicare managed care. Health Care Financ Rev
Lyden PD, Lu M, Levine SR, Brott TG, Broderick J; NINDS rtPA Stroke Study Group. A modified National Institutes of health stroke scale for use in stroke clinical trials: Preliminary reliability and validity. Stroke
Suenkeler IH, Nowak M, Misselwitz B, Kugler C, Schreiber W, Oertel WH, Back T. Timecourse of health-related quality of life as determined 3, 6 and 12 months after stroke. Relationship to neurological deficit, disability and depression. J Neurol
Khaw WF, Hassan ST, Latiffah AL. Health-related quality of life among hypertensive patients compared with general population norms. J Med Sci
Cífková R, Wohlfahrt P, Krajèoviechová A, Jozífová M, Mayer O Jr., Vanìk J, Hlinovský D, Kielbergerová L, Lánská V. Blood pressure control and risk profile in poststroke survivors: A comparison with the general population. J Hypertens
Lalonde L, Clarke AE, Joseph L, Mackenzie T, Grover SA; Canadian Collaborative Cardiac Assessment Group. Health-related quality of life with coronary heart disease prevention and treatment. J Clin Epidemiol
Badshah M. Association of dyslipidemia and ischemic stroke. Ann Pak Inst Med Sci
Zahid N, Claussen B, Hussain A. High prevalence of obesity, dyslipidemia and metabolic syndrome in a rural area in Pakistan. Diabetes Metabol Syndrome Clin Res Rev
Walfridsson H, Walfridsson U, Nielsen JC, Johannessen A, Raatikainen P, Janzon M, Levin LA, Aronsson M, Hindricks G, Kongstad O, Pehrson S, Englund A, Hartikainen J, Mortensen LS, Hansen PS. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation: Results on health-related quality of life and symptom burden. The MANTRA-PAF trial. Europace
Ha AC, Breithardt G, Camm AJ, Crijns HJ, Fitzmaurice GM, Kowey PR, Le Heuzey JY, Naditch-Brûlé L, Prystowsky EN, Schwartz PJ, Torp-Pedersen C, Weintraub WS, Dorian P. Health-related quality of life in patients with atrial fibrillation treated with rhythm control versus rate control: Insights from a prospective international registry (registry on cardiac rhythm disorders assessing the control of atrial fibrillation: RECORD-AF). Circ Cardiovasc Qual Outcomes
Al-Jadid MS, Robert AA. Determinants of length of stay in an inpatient stroke rehabilitation unit in Saudi Arabia. Saudi Med J
al-Rajeh SM, Larbi EB, al-Freihi H, Ahmed K, Muhana F, Bademosi O. A clinical study of stroke. East Afr Med J
Hopman WM, Harrison MB, Coo H, Friedberg E, Buchanan M, VanDenKerkhof EG. Associations between chronic disease, age and physical and mental health status. Chronic Dis Can
Abubakar SA, Isezuo SA. Health related quality of life of stroke survivors: Experience of a stroke unit. Int J of Biomed Sci
Wu X, Min L, Cong L, Jia Y, Liu C, Zhao H, Liu P, Luo Y. Sex differences in health-related quality of life among adult stroke patients in Northeastern China. J Clin Neurosci
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]