Pilot trial of a tele-rehab intervention to improve outcomes after stroke in Ghana: A feasibility and user satisfaction study

doi:10.1016/j.jns.2018.01.039

Journal of the Neurological Sciences

Volume 387, 15 April 2018, Pages 94-97

https://doi.org/10.1016/j.jns.2018.01.039 Get rights and content

Highlights

•
Rehabilitation services are severely limited in sub Saharan Africa.
•
Tele-rehabilitation holds promise for under-resource settings.
•
We assessed feasibility of a mobile technology-assisted physical therapy program for stroke survivors in Ghana.
•
The intervention was associated with improvements in motor deficits.
•
Tele-rehabilitation is feasible in resource-limited settings.

Abstract

Background

Tele-rehabilitation after stroke holds promise for under-resourced settings, especially sub-Saharan Africa (SSA), with its immense stroke burden and severely limited physical therapy services.

Objective

To preliminarily assess the feasibility and outcomes of mobile technology-assisted physical therapy exercises for stroke survivors in Ghana.

Methods

We conducted a prospective, single arm, pre-post study involving 20 stroke survivors recruited from a tertiary medical center, who received a Smartphone with the 9zest Stroke App® to deliver individualized, goal-targeted 5-days-a-week exercise program that was remotely supervised by a tele-therapist for 12 weeks. Outcome measures included changes in stroke levity scale scores (SLS), Modified Rankin score (MRS), Montreal Cognitive Assessment (MOCA), and feasibility indicators.

Results

Among study participants, mean ± SD age was 54.6 ± 10.2 years, 11 (55%) were men, average time from stroke onset was 6 months. No participants dropped out. Compared with baseline status, mean ± SD scores on SLS improved from 7.5 ± 3.1 to 11.8 ± 2.2 at month 1 (p < 0.0001) and 12.2 ± 2.4 at month 3 (p < 0.0001), MOCA scores improved from 18.2 ± 4.3 to 20.4 ± 4.7 at month 1 (p = 0.14), and 22.2 ± 7.6 at month 3 (p = 0.047). Mean ± SD weekly sessions performed by participants per month was 5.7 ± 5.8 and duration of sessions was 25.5 ± 16.2 min. Erratic internet connectivity negatively affected full compliance with the intervention, although satisfaction ratings by study participants were excellent.

Conclusion

It is feasible to administer an m-health delivered physical therapy intervention in SSA, with high user satisfaction. Randomized trials to assess the efficacy and cost-effectiveness of this intervention are warranted.

Introduction

Rehabilitation after stroke in sub-Saharan Africa (SSA) is challenged by lack of trained rehabilitation personnel, with 2.5 physiotherapists 100,000 people served [1]. Stroke survivors often resort to alternative forms of treatment and refuse orthodox care due to highly prevalent stroke related stigma [2]. Furthermore, 70% of individuals in SSA reside in rural settings [3] with limited geographic access to rehabilitation services which coupled with the prohibitive costs make post-stroke rehabilitation a major challenge.

One promising avenue for effective mobilization and utilization of the scanty health professionals available to meeting the huge population demand in LMICs for neurology care is via the agency of telemedicine [4,5]. Tele-rehabilitation has been evaluated for feasibility and efficacy and data pooled from 7 studies provided limited, moderate evidence that tele-rehabilitation had equal effects with conventional rehabilitation in improving abilities of activities of daily living and motor function for stroke survivors [6].

However, the feasibility of m-health administered rehabilitation for stroke survivors has not been tested in SSA. Hence the objective of the present study was to preliminarily assess the feasibility of and satisfaction with a comprehensive physical therapy tele-rehabilitation intervention for post-stroke rehabilitation among 20 recent Ghanaian stroke survivors.

Section snippets

Study design and site

This is a single site, single arm, observational prospective pilot study to assess the feasibility of a mobile phone administered physical therapy intervention administered remotely at home of Ghanaian stroke survivors. The study was conducted at the Neurology Clinic of the Komfo Anokye Teaching Hospital (KATH), a tertiary medical center in Kumasi, Ghana [7].

Study participants

Consecutive stroke survivors attending the Neurology service at KATH were approached for enrollment into the study after obtaining

Demographic and clinical characteristics of study participants

Of the 24 stroke patients approached, 20 were eligible for this feasibility study. Of those excluded, 3 had fully recovered from stroke without demonstrable motor deficits and 1 declined enrollment into the study. The mean ± SD age of study subjects was 54.6 ± 10.2 years, 11 of whom were male participants and 15 (75%) resided in urban settings and other characteristics are shown in Table 1.

Outcomes

The mean score on the stroke levity scale at enrollment was 7.5 ± 3.1 which increased to 11.8 ± 2.2 at

Discussion

We demonstrate for the first time the feasibility of and high user satisfaction involved with deploying a mobile phone delivered domiciliary rehabilitation intervention for stroke survivors in a challenging resource-limited setting in West Africa. Overall, the intervention was associated with improvements in baseline motor deficits over the 12 weeks of follow-up. This study builds upon our initial survey in this Ghanaian population where we found ≈ 60% of stroke survivors were functionally

Conflicts of interest

None declared by authors.

Funding for study

National Institute of Health- National Institute of Neurological Disorders & Stroke; R21 NS094033 and R21 NS103752-01; National Institute of Health- Forgarty International Center R21 TW010479-01.

References (15)

F.S. Sarfo et al.
Stroke-related stigma among west Africans: patterns and predictors
J. Neurol. Sci.
(2017)
F.S. Sarfo et al.
Tele-neurology in sub-Saharan Africa: a systematic review of the literature
J. Neurol. Sci.
(2017)
J. Chen et al.
Telerehabilitation approaches for stroke patients: systematic review and meta-analysis of randomized controlled trials
J. Stroke Cerebrovasc. Dis.
(2015)
F.S. Sarfo et al.
Profile of neurological disorders in an adult neurology clinic in Kumasi, Ghana
eNeurologicalSci.
(2016)
F.S. Sarfo et al.
Potential role of tele-rehabilitation to address barriers to implementation of physical therapy among West African stroke survivors: a cross-sectional survey
J. Neurol. Sci.
(2017)
F.S. Sarfo et al.
Response by Sarfo and Ovbiagele to letter regarding “Potential role of tele-rehabilitation to address barriers to implementation of physical therapy among West African stroke survivors: a cross-sectional survey”
J. Neurol. Sci.
(2017)
M. Nichols et al.
Assessing mobile health capacity and task shifting strategies to improve hypertension among Ghanaian stroke survivors
Am J Med Sci
(2017)

There are more references available in the full text version of this article.

Cited by (46)

Current evidence on the use of mHealth approaches in Sub-Saharan Africa: A scoping review
2023, Health Policy and Technology
Mobile health (mHealth) approaches are especially beneficial to Sub-Saharan Africa (SSA), which has a disproportionate disease burden and a scarcity of healthcare workers.
This study aims to assess the availability, stage, and targeted health issues of mHealth interventions in SSA and to identify the gaps.
The study employed a scoping review guided by Arksey and O'Malley's framework to explore the use of mHealth in SSA. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used to report the review in a transparent and comprehensive manner. Articles published from 2000 to 2021 were searched in PUBMED, IEEE, SCOPUS, and Web of Science and evaluated with set of inclusion criteria. Data from the included publications were retrieved and synthesized.
A total of 1020 articles were found. 59 of these have met the criteria for inclusion. The results show the implementation of mHealth interventions in 21 SSA nations. Only 1 (2%) mHealth interventions used a wearable sensor-based approach. 13 (22%) were SMS text-based interventions, 17 (29%) were app-based mHealth approaches, 18 (30%) were telemedicine-based approaches, and 10 (17%) were mixed approaches. HIV, cancer, and maternal and child health problems are the most commonly discussed health issues. Proof of concept, design and development, a pilot test were the frequently documented stages of mHealth interventions.
Less than half of SSA countries incorporate mHealth platforms, highlighting the need for further development. Integrating wearable based platforms for real-time monitoring of physiological parameters demands careful consideration.
Mobile health (mHealth) technology is believed to be very beneficial for Sub-Saharan Africa (SSA) nations where there is a high disease burden but inadequate healthcare system. Evidence-based data on the use and implementation of mHealth systems is needed to trace implementation and fill existing gaps. We performed a scoping review to determine the current availability, use, and stage of mHealth interventions and targeted health services in SSA. 21 SSA nations made (few) attempts in designing and implementing of mHealth systems. HIV, cancer, and maternal and child health are some of the health services among others. Though few large-scale implementations were reported, most interventions are at an early stage. mHealth solution should be designed to be both economical and simple to use to increase its uptake and incorporate wearables for real-time monitoring of physiological parameters.
Long-term determinants of death after stroke in Ghana: Analysis by stroke types & subtypes
2022, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Future studies should include assessment of rates of stroke recurrence and the impact of secondary prevention strategies in mitigating adverse outcomes of stroke in the African context. This will help inform the design of clinical trials aiming to mitigate adverse cardiovascular outcomes,27–31 post-stroke comorbidities32–37 and functional recovery38,39 after stroke in Africa. Approximately 3 out of 4 Ghanaians diagnosed with stroke die within 8 years after admission with stroke.
Determinants of long-term mortality after stroke by mechanistic type and subtype are unknown in sub-Saharan Africa (SSA). Such data are crucial for targeting specific pathophysiologic pathways to improve stroke outcomes in the region.
To evaluate rates and predictors of mortality up to 8 years after stroke, by type and subtype, in Ghana.
We prospectively collected data on stroke patients presenting at a tertiary medical facility in Ghana between 2013 and 2018 who were followed up until October 31, 2021. Stroke diagnosis was confirmed using a Computerized Tomography scan; ischemic strokes were mechanistically typed using the TOAST classification while intracerebral hemorrhages were subtyped using the SMASH-U scheme. Demographic and clinical predictors of stroke mortality were evaluated using Cox proportional hazards regression modelling.
Of 564 patients encountered during the study period, data on vital status were available for 556 (98.6%) subjects at discharge and 442 (78.4%) on follow-up. Mean age was 61.1 $\pm$ 15.1 years, and 223 (53.1%) were male. Mortality rates at 1, 3, 12, 36, 60 and 96 months were 37.5%, 43.2%, 49.7%, 57.4%, 62.9%, and 73.7% respectively. Three (3) factors remained significantly associated with risk of death namely age, adjusted hazard ratios (aHR) of 1.12 (95%CI: 1.04-1.20), no formal education 1.36 (95% CI: 1.02-1.81) and modified Rankin score 1.67 (95%CI: 1.42 – 1.98) for each unit rise. For ischemic stroke the four (4) factors associated with long-term mortality were low formal education, low monthly income, having diabetes mellitus and higher functional score on admission. For intracerebral hemorrhage, the two factors were increasing age and high functional score.
Stroke severity is the key predictor of long-term mortality after an index stroke in Ghana, regardless of the underlying pathophysiologic mechanism. Instituting acute stroke systems of care to facilitate timely reperfusion efforts may greatly improve long term survival outcomes after stroke in SSA.
Feasibility, acceptability, and appropriateness of a mobile health stroke intervention among Ghanaian health workers
2022, Journal of the Neurological Sciences
mHealth interventions can improve care delivery in settings with limited resources. The Phone-based Interventions under Nurse Guidance after Stroke (PINGS) is a nurse-led, mHealth-centered approach to blood pressure (BP) control among recent stroke survivors with hypertension in Ghana. It has 4 key components: (1) home blood pressure monitoring, (2) nurse-coordinated mhealth consults, (3) phone alerts as medication reminders, and (4) patient motivational messages delivered as interactive voice recordings.
To assess the feasibility, acceptability, and appropriateness for scale up of the PINGS intervention in Ghana, from the perspective of health workers.
Between July and August 2021, we deployed an online questionnaire describing the components of PINGS to a cross-section of health workers in Ghana. The questionnaire used an adaptation of psychometrically validated Likert scale measures to elicit agreement or disagreement with attributes of the intervention. The questionnaire was distributed online to approximately 4000 healthcare workers via email and social media platforms. A summary of descriptive statistics was obtained; summed composite scores were then calculated, dichotomized, and binary logistic regression performed using R programming software.
Of 653 health workers who completed the survey, 57.2% were male; 73.2% clinicians; median age was 33 years (IQR 29, 37). Respondents' primary workplaces were public (64.4%), quasi-government (9.4%), and private, including mission-based (26.2%) facilities. PINGS was deemed feasible, acceptable, and appropriate by 93.9%, 94.8%, and 95.1% of respondents respectively. Clinical staff had higher odds of finding PINGS feasible (OR 4.10; C.I. 2.15, 8.0; p < 0.001), acceptable (OR 3.76, C.I. 1.87, 7.69; p < 0.001), or appropriate (OR 2.91, C.I. 1.41, 5.95; p = 0.004) compared to non-clinical staff. There was no statistically significant difference in the rating of each measure when analyzed by age, sex, years of health work experience, geographic location, type, or level of health facility.
An overwhelming majority of health workers (particularly clinical staff) considered PINGS to be a feasible, acceptable, and appropriate for BP control among stroke survivors in Ghana.
Views of Service Users, Their Family or Carers, and Health Care Professionals on Telerehabilitation for People With Neurological Conditions in Ghana: Qualitative Study
2024, JMIR mHealth and uHealth
Effect of mobile application types on stroke rehabilitation: a systematic review
2023, Journal of NeuroEngineering and Rehabilitation
mHealth in sub-Saharan Africa and Europe: A systematic review comparing the use and availability of mHealth approaches in sub-Saharan Africa and Europe
2023, Digital Health

View all citing articles on Scopus

View full text

Clinical Short CommunicationPilot trial of a tele-rehab intervention to improve outcomes after stroke in Ghana: A feasibility and user satisfaction study

Highlights

Abstract

Background

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Study design and site

Study participants

Demographic and clinical characteristics of study participants

Outcomes

Discussion

Conflicts of interest

Funding for study

J. Neurol. Sci.

J. Neurol. Sci.

J. Stroke Cerebrovasc. Dis.

eNeurologicalSci.

J. Neurol. Sci.

J. Neurol. Sci.

Am J Med Sci

Clinical Short Communication
Pilot trial of a tele-rehab intervention to improve outcomes after stroke in Ghana: A feasibility and user satisfaction study