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INTRODUCTION

The World Health Organization (WHO) defines “Stroke” as a rapidly developing signs of focal (or global) disturbance of cerebral function with symptoms lasting for ≥24 hours, or leading to death with no apparent cause other than vascular origin. The stroke is a collection of clinical syndromes which can be resulting from ischemia in the cerebrum to intracranial hemorrhage. (1) In 2016, the Global Burden of Disease project in India recorded an estimated 1,175,778 new cases of stroke. The annual stroke incidence in India is estimated to be between 105 and 152 cases per 100,000 individuals, according to a recent systematic review that primarily relied on cross-sectional data. (2) Over the past decade, the incidence of stroke in India has significantly risen. This increase can be linked to various socio-economic changes that have influenced lifestyles, including reduced physical activity, higher consumption of processed foods, and greater workplace stress. These shifts have also contributed to the rise in risk factors such as type-2 diabetes, hypertension, obesity, and hyperlipidaemia. Approximately 80% of all strokes in India are ischemic in nature. Additionally, strokes affect around 10% to 15% of individuals under the age of 40. Based on community survey data, Dalal et al. reported a crude prevalence rate of 200 cases per 100,000 population for stroke-induced hemiplegia in different parts of India. (3). Statistics indicate that in 2019, India experienced 1.29 million stroke incidents (95% UI 1.15–1.45) and 699,000 stroke-related deaths (95% UI 594,000–807,000). (4) The consequences of stroke can significantly limit survivors' independence and activity levels, reducing their ability to perform daily tasks and meet societal responsibilities. More than half of stroke survivors in India suffer from motor impairments yet do not receive physiotherapy services, presenting a major challenge. These impairments restrict activities such as dressing, walking, bathing, eating, cooking, shopping, and managing household chores, which impacts not only personal autonomy but also the overall quality of life for families. (5) The temporal progression following a stroke is often classified into specific phases as outlined by the Stroke Roundtable Consortium. These phases include the hyper-acute phase (first 24 hours), acute phase (first 7 days), early sub-acute phase (first 3 months), late sub-acute phase (months 4–6), and chronic phase (beyond 6 months). Shortly after the onset of cerebral ischemia, a series of plasticity-enhancing mechanisms occurs, resulting in dendritic growth, axonal sprouting, and the formation of new synapses. The most significant recovery typically occurs within the first few weeks’ post-stroke, with progress often plateauing after three months, particularly for motor symptoms. (6) Ordinal scales are frequently used in Indian stroke rehabilitation researches to assess body structure and function as outcome measures.

The reliability and validity of these scales range from 0.37 to 1.00 and 0.65 to 0.96, respectively. Among the most commonly used outcome measures are the Modified Rankin Scale (m-RS) and Barthel Index. Nevertheless, there is a need to adapt and validate scales that assess activity limitations and participation to ensure they are culturally appropriate. It is worth noting that certain items on these scales may be understood differently in the Indian context. (7) According to earlier research, the common participation measures in stroke rehabilitation do not adequately address the unique post-stroke concerns of patients in non-Western countries like India. Indian stroke patients (38%–50%) reported that the information in these measures was "not a problem" or "not relevant" for them. Disparities in regional customs, lifestyles, and architectural settings have been blamed for this disparity. It is crucial to remember that non-Western cultural contexts, such as India, were not initially considered when developing these outcome measures. (8) 

The Indian Stroke Scale (ISS) is a patient-reported outcome measure designed specifically to evaluate limitations experienced by stroke patients in India. It focuses on assessing activities that are both meaningful and culturally relevant to the patients’ daily lives. With a Cronbach's alpha score of 0.94, the scale has demonstrated excellent internal consistency. Additionally, confirmatory factor analysis results have demonstrated an acceptable goodness of fit. The scale has also shown robust construct validity and a high test-retest reliability, with an intraclass correlation coefficient of 0.80. It effectively distinguishes between patients with varying levels of disability severity, showing a mean difference of 34 (95% CI = 27 to 39).The ISS has shown a moderate correlation with the Barthel Index (r = 0.59, p <.001), the social participation domains of the Stroke Impact Scale (r = 0.44, p <.001), and the physical and instrumental activities of daily living (r = 0.64, p <.001). Originally created in English, the questionnaire was subsequently translated and field-tested in Tamil and Gujarati, two Indian languages. (8)

Aim:     

• To find Functional problems faced by the patient after acute stroke and the recovery status after 3 months

Objectives:  

1. To observe and evaluate the chief functional problems in patients with stroke in acute phase of incident.
2. To know the prevalence of population who take the physiotherapy rehabilitation after discharge from hospital.
3. To observe and evaluate the chief functional problems felt at the 3 months of the incident.
4. To compare the severity of functional problems from the point of incident to 3 months post incident.

REVIEW OF LITERATURE

1. Stephanie P Jones et.al. (2022), have done a systematic review of the incidence, prevalence, and case fatality of stroke in India. They examined prospective, consecutive recruitment studies with a predetermined sampling strategy that were conducted between January 1997 and August 2020. Studies were included if participants met clinical criteria or the World Health Organization's (WHO) definition of a confirmed history of stroke. Nine studies have been selected for inclusion.  There were 22,479,509 people in the total population, and 11,654 (mean 1294 SD 1710) of them had an incident stroke. The crude annual incidence rate varied from 108/100,000 to 172/100,000 individuals annually in seven studies. (2)
2. V Prakash and Mohan Ganesan (2020) The Indian Stroke Scale was created and validated to assess stroke patients' involvement in everyday activities in India. Psychometric testing and scale development were the two stages of the scale's development. The items emerged from a conceptual framework of stroke patients' involvement in everyday activities in an Indian setting. There were twenty-five items in the scale's final version. In all, 377 stroke patients were selected from five physiotherapy outpatient rehabilitation facilities and two tertiary care hospitals in India. Internal consistency, one-dimensionality, construct validity (known group and convergent validity), and test-retest reliability were all examined during the scale's psychometric testing. The scale's items showed good internal consistency, according to their findings (Cronbach's alpha =.94).
3. V. Prakash and Mohan Ganesan (2019) studied what matters to patients with stroke in India and why? Which was a qualitative study, in which they have taken 30 patients who were diagnosed with stroke for the first time and aged > 45 years from the rural areas of Gujarat and Tamilnadu states of India.
4. B. Bonnera, R. Pillai et al. (2015) investigated the factors predicting return to work after stroke in India. The study included patients aged 18–60 with mild to moderate disability following a first-ever stroke. The findings showed that 52.5% of patients returned to work, with 86.5% returning to their previous employer. The average time from stroke to return to work was 3.9 to 4.6 months, with 59% returning within 3 months. Among those unable to return to work, 94% expressed a desire to do so. Fatigue (74%) and feeling of not having fully recovered (77%) were reported as major concerns among those who returned to work. (13)  

MATERIALS AND METHODS

Methodology :

• Study Design: - cross - sectional
• Sample size: - 48
• Study population: - Stroke patients.
• Source of data: - Shree B.G. Patel College of Physiotherapy, Jeevendeep Hospital, Anand., Lifeline Hospital, Anand

• Sampling Method: - Purposive
• Study Duration: - 1 year

Criteria for sample selection:

• Inclusion Criteria: -

• Patients diagnosed with and are in acute phase of stroke (< 7 days)
• Ischemic and haemorrhagic stroke
• Patients with MMSE >23
• Age > 40
• Patients who are willing to participate.

• Exclusion Criteria: -

• Patients with previous history of any neurological disorders.
• Patients who had undergone any major surgical procedures within 6 months of the incident.

Materials used: -

• Consent form
• Assessment form and Mini Mental State Examination (MMSE) scale 
• Indian Stroke Scale
• Pen and paper

Procedure:

RESULTS

Statistical analysis was done in the SPSS version 25.

Descriptive Statistics
	N	Minimum	Maximum	Mean	Std. Deviation
AGE	27	40	80	60.6667	12.4499
Duration of hospital stay (days)	27	2	40	11	8.43071
MMSE	27	23	30	26.5185	2.60724
ISS pre	27	0	100	48.4815	36.1454

Table 1 Descriptive  Statistics

 

Table 2. Test for Normality of the data (Pre-Post 3 months) : the test of normality done for the difference of the ISS pre and Post 3 months score and according to Shapiro wilk test of normality significance is 0.019 which is <0.05 concluding that the data is not normally distributed.

	Pre	Post 3 months	Difference	P.value
Mean (SD)	48.4074(36.17)	87.4815(19.48)	39.0741(28.17)	P<0.001
Median (IQR)	31.000(20.00-91.000)	99.000(85.00-100.000)	43.00(9.00-64.00)	P<0.001

Table 3. Mean with Standard deviation, Median with Interquartile Ranges and of pre post scores of ISS and its difference. (p<0.001)

Figure 1 Indian stroke scale pre- post comparison

Figure 1 is a representation of all 25 questions’ responses’ average, of all 27 subjects’ pre- and post-3 month’s functional status. As ISS is a 5-point scale ranging from “not limited at all” to “completely limit”, the bar graph shows each question’s separate response to identify the actual status at both the time when the data is taken.

	Patients who have not taken physiotherapy			Patients who have taken the Physiotherapy
ISS Initial	ISS post 3 months	Difference	ISS Initial	ISS post 3 months	Difference
100	100	0	91	100	9
0	44	44	56	89	33
15	85	70	100	100	0
71	100	29	25	100	75
54	99	45	6	33	27
91	100	9	21	94	73
99	100	1	99	100	1
26	100	74	22	93	71
18	100	82	10	71	61
31	95	64	31	90	59
92	100	8	1	64	63
100	100	0	36	90	54
66	100	34	20	63	43
58.6923	94.0769	35.385+30.31	26	52	26
			38.85714	81.35714	42.5 + 26.63

Table 4 Initial and post total scores of ISS in with difference of patients who have taken the physiotherapy and those who have not.

• To take a larger sample size was out of the scope of the study, so future studies should include larger sample size.
• Due to the limitation of study duration this study focuses on the recovery of stroke after
• 3 months which is till sub-acute phase only, the further recovery status of chronic stages can be evaluated in future studies with the help of same outcome measure.
• This study includes sample from only few hospitals of Anand city and one outpatient centre which may not be representative of general population, hence future studies should consist a multi-centre sample from various geographical locations.
• The age range is quite large in this study, so a study with narrowed age range should be done which can differentiate the prognosis.
• The initial assessment was taken in the form of in person interview while the post status was taken via telephonic interview which can lead to biases in the results, so the future studies can be done with in person interviews only.
• Limitations and Future Directions: This study focused on examining functional ecovery in stroke patients, regardless of the brain areas affected. However, the time constraint of this study (1 year) limited the exploration of long-term recovery patterns. Future research should investigate recovery trajectories beyond 1 year to provide a more comprehensive understanding of stroke rehabilitation outcomes.

ACKNOWLEDGEMENT

• Dr Manoj Kumar (PT) , For Guiding me thoroughly during the reserach
• Dr. Raisa Anand and Dr. Himanshu Patel to let allow to collect data and conduct the research in their hospital premises

REFERENCES

1. Vaidya C, Majmudar D. A retrospective study of clinical profile of stroke patients from GMERS Medical College and Hospital, Gandhinagar, Gujarat. Int J Clin Trials. 2014;1(2):62–6.https://doi.org/10.5455/2349-3259.ijct20140805
2. Jones SP, Baqai K, Clegg A, Georgiou R, Harris C, Holland EJ, et al. Stroke in India: A systematic review of the incidence, prevalence, and case fatality. Int J Stroke. 2022;17(2):132–40.https://pubmed.ncbi.nlm.nih.gov/34114912/
3. Khurana S, Gourie-Devi M, Sharma S, Kushwaha S. Burden of Stroke in India during 1960 to 2018: A Systematic Review and Meta-Analysis of Community Based Surveys. Neurol India. 2021;69(3):547–59.DOI: 10.4103/0028-3886.317240
4. The burden of neurological disorders across the states of India: The Global Burden of Disease Study 1990–2019 Singh, Gagandeep et al. The Lancet Global Health, Volume 9, Issue 8, e1129 - e1144
5. Bharati B, Sahu KS, Pati S. Rehabilitation of Stroke Patients in India: An Exploratory Study from a National-Level Survey Data. Indian J PhysiotherOccup Ther - An Int J. 2021;15(3):8–18.https://doi.org/10.37506/ijpot.v15i3.16457
6. Grefkes C, Fink GR. Recovery from stroke: current concepts and future perspectives. Neurol Res Pract. 2020;2(1).https://doi.org/10.1186/s42466-020-00060-6
7. Mani K, Sundar S. Outcome Measures Used in Stroke Rehabilitation in India: A Scoping Review. Indian J Occupational Therapy (Wolters Kluwer India Pvt Ltd) [Internet]. 2018;50(4):111–8.DOI:10.4103/ijoth.IJOTH_9_18
8. Prakash V, Ganesan M. The Indian Stroke Scale: Development and validation of a scale to measure participation in daily activities among patients with stroke in India. Int J Stroke. 2021;16(7):840–8.DOI: 10.1177/1747493020979361
9. Activity Limitations of Patients with Stroke Attending Out-patient Facilities in the Western Cape , South Africa. 2011;16–22.https://doi.org/10.4102/sajp.v67i2.41
10. Wade DT, Wood VA, Hewer RL. Recovery after stroke The first 3 months. 1985;7–13.DOI: 10.1136/jnnp.48.1.7
11. Bharati B. Rehabilitation of Stroke Patients in India : An Exploratory Study from a Rehabilitation of Stroke Patients in India : An Exploratory Study from a National-Level Survey Data. 2021;(July)https://doi.org/10.37506/ijpot.v15i3.16457
12. Prakash V, Ganesan M. What matters to patients with stroke in India and why: a qualitative study. DisabilRehabil [Internet]. 2021;43(18):2585–92. Available from: https://doi.org/10.1080/09638288.2019.1706194
13. Bonner B, Pillai R, Sarma PS, Lipska KJ, Pandian J, Sylaja PN. Factors predictive of return to work after stroke in patients with mild-moderate disability in India. Eur J Neurol. 2016;23(3):548–53.https://doi.org/10.1111/ene.12887