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Verma SJ, Gulati P, Injety RJ, Arora D, Dhasan A, Singhania A, Khatter H, Sharma M, Sylaja PN, Pandian JD. Secondary prevention by structured semi-interactive stroke prevention package in INDIA (SPRINT INDIA): Findings from the process evaluation of a randomized controlled trial. Eur Stroke J 2023; 8:1053-1063. [PMID: 37585729 PMCID: PMC10683732 DOI: 10.1177/23969873231192291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 07/02/2023] [Indexed: 08/18/2023] Open
Abstract
INTRODUCTION Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in INDIA Trial delivered secondary stroke awareness intervention to sub-acute stroke patients in form of workbook, videos and SMS across 31 centres in 12 languages. Trial was stopped for futility due to fewer vascular outcomes than anticipated. Trial results indicated that trial intervention, did not lead to reduction in vascular events. We carried out process evaluation, to evaluate trial implementation and participant's perspectives, to comprehend the trial's futile outcomes. MATERIALS AND METHODS Using mixed methods approach, qualitative interviews and quantitative data from case report forms, workbooks and questionnaires were analysed to measure intervention fidelity and contamination. Using purposive sampling, 115 interviews of patient-caregiver dyads and health professionals at 11 centres and 2 focus group discussions were held. RESULTS AND DISCUSSION Iterative thematic analysis of qualitative data was done with RE-AIM and realist models. There was good fidelity to intervention and adherence to protocol; however, there was dilution of inclusion criteria by randomly enrolling uneducated and caregiver-dependent patients. Centre coordinators provided counselling to both arms, not specified by protocol, causing bias. Coordinators found it difficult to keep patients motivated to view intervention which was corroborated by fidelity questionnaire showing decreased viewing of intervention for a year. Cardiovascular protection improved in routine care by virtue of participating in trial. No contamination of intervention was reported. CONCLUSION The intervention was acceptable by patients and caregivers, which could be made a community-based programme. Reasons identified for decreased viewing were repetitive content and non-availability of personal cellular device.
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Affiliation(s)
- Shweta Jain Verma
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Puja Gulati
- School of Pharmacy, Desh Bhagat University, Mandi Gobindgarh, Punjab, India
| | - Ranjit J Injety
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Deepti Arora
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Aneesh Dhasan
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Anusha Singhania
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Himani Khatter
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Meenakshi Sharma
- Non-Communicable Diseases Section, Indian Council of Medical Research, New Delhi, India
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Sylaja PN, Nair JPR, Kate MP, Dhasan A, Nambiar V, Narayan S, Renjith V, Arora D, Verma SJ, Sharma M, Dhaliwal R, Khatter H, Sarma PS, Pandian JD. Ayurvedic Treatment in the Rehabilitation of Ischemic Stroke Patients in India: A Randomized Controlled Trial Study Protocol. Cerebrovasc Dis 2023; 52:609-615. [PMID: 37023741 DOI: 10.1159/000530546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 03/22/2023] [Indexed: 04/08/2023] Open
Abstract
In patients with ischemic stroke, motor and sensory impairments are common and are associated with functional disability. Conventional physiotherapy (CP) is the primary modality of rehabilitation for post-stroke sensorimotor dysfunction. Ayurveda is a commonly practiced alternative system of medicine that offers unique rehabilitative measures for post-stroke recovery. We hypothesize that Ayurvedic rehabilitative treatment (ART) is superior to similar duration CP in improving the sensorimotor recovery of patients with ischemic stroke at 90 days after enrollment. AyuRvedic TrEatment in the Rehabilitation of Ischemic STrOke Patients in India: A Randomized controllEd trial (RESTORE) is an investigator-initiated, multicenter, prospective, randomized, controlled, parallel-arm, blinded outcome assessment trial being conducted under the Indian Stroke Clinical Trial (INSTRuCT) Network across the four comprehensive stroke centers in India. Consecutive hemodynamically stable adult patients with their first acute ischemic stroke between 1 and 3 months from stroke onset are being randomized (1:1) into two treatment groups to receive either 1 month of ART or 1 month of CP. The primary outcome measure is the Fugl Meyer Assessment-upper extremity for physical performance at 90 days. The secondary outcomes are the modified Rankin Scale, Barthel Index, Berg Balance, and SF-36 at 90 days. The safety outcomes include a composite of irreversible morbidity and mortality. A sample size of 140 (70 in each group) patients with ischemic stroke will allow us to detect a minimal clinical important difference of 9.4 (standard deviation) with superiority margin of 5, an attrition rate of 10%, alpha of 5%, and power of 80%. This randomized trial will systematically assess the efficacy and safety of traditional ART compared to CP. The trial has been registered in the Clinical Trial Registry India (CTRI/2018/04/013379).
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Affiliation(s)
- Padmavathy Narayana Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | | | | | - Aneesh Dhasan
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Vivek Nambiar
- Department of Neurology, Amrita Institute of Medical Sciences, Kochi, India
| | - Sunil Narayan
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Vishnu Renjith
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Deepti Arora
- Department of Neurology, Christian Medical College, Ludhiana, India
| | | | - Meenakshi Sharma
- Non-Communicable Diseases Section, Indian Council of Medical Research, New Delhi, India
| | - Rupinder Dhaliwal
- Non-Communicable Diseases Section, Indian Council of Medical Research, New Delhi, India
| | - Himani Khatter
- Department of Neurology, Christian Medical College, Ludhiana, India
| | - P S Sarma
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
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Sharma A, Cherian RJ, Pandey RA, Khatter H, Paul R, John B. Clinico-Radiological and Functional Outcome of Difficult Talipes Equinovarus Deformity Corrected With an Ilizarov Fixator. J Foot Ankle Surg 2022; 61:719-725. [PMID: 34893424 DOI: 10.1053/j.jfas.2020.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/29/2020] [Accepted: 10/27/2020] [Indexed: 02/03/2023]
Abstract
Relapsed, resistant, and untreated congenital talipes equinovarus poses significant challenges in view of functional outcome following conventional serial casting and soft tissue release procedures. The Ilizarov ring fixator here offers significant possibilities as an extended conservative treatment modality. The aim of the present study was to critically evaluate effectiveness of the Ilizarov ring fixator with regard to radiological, clinical, and functional outcomes, in the difficult clubfeet. The study was carried out on patients presenting with relapsed, resistant, or untreated congenital talipes equinovarus deformity, who underwent deformity correction using the Ilizarov ring fixator application. All patients were reviewed at 6 monthly intervals for over 3 years following fixator removal with an objective clinical, radiological, and functional assessment. Twenty-three patients with 30 clubfeet were enrolled in our study. The mean age was 8.3 ± 3.6 (range 4-17) years. The postoperative clinical, radiological, and functional scores showed statistically significant improvement among all patients when compared with the preoperative data. All 30 feet developed varying complications during treatment with pin track infections being the most common. However, they were managed while continuing the distraction correction process. The Ilizarov ring fixator is an effective and reliable solution for difficult and challenging clubfeet. However, one must be aware of a strict adherence to a bracing protocol to avoid recurrence of deformities. A regular periodical functional and clinical follow up must be ensured among these children for a favorable outcome.
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Affiliation(s)
- Amit Sharma
- Senior Resident, Department of Orthopaedics, All India Institute of Medical Science (AIIMS), Jodhpur, Rajasthan, India
| | - Rajit John Cherian
- Assistant Professor, Department of Orthopaedics, Malankara Orthodox Syrian Church (MOSC) Medical college & Hospital, Kolenchery, Kerala, India
| | - Ritesh Arvind Pandey
- Associate Professor, Department of Orthopaedics, Christian Medical College and Hospital, Ludhiana, Punjab, India.
| | - Himani Khatter
- Assistant Professor cum Statistician, Department of Community Medicine and Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Rajesh Paul
- Professor, Department of Orthopaedics, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Bobby John
- Professor, Department of Orthopaedics, Christian Medical College and Hospital, Ludhiana, Punjab, India
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Kalra LP, Khatter H, Kulkarni A, Sahonta R, Rathore S, Hattingen E, You SJ, Wagner M, Weidauer S, Keil F, Pandian JD, Foerch C. Reliability of Instant Messaging-Based Evaluation of Brain Imaging in Acute Stroke. Stroke 2022; 53:e246-e250. [PMID: 35506382 DOI: 10.1161/strokeaha.121.037274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of instant messenger applications among physicians has become common in acute stroke management, especially in developing countries. Photos or video sequences of brain computed tomography (CT) scans are being sent to receive real-time support in assessing radiological findings. We analyzed whether instant messaging-based evaluation is precise enough to extract relevant information from the images. METHODS In this prospective study, anonymized videos and photos of CT and CT angiography scans of patients with symptoms of acute stroke were recorded from the diagnostic monitor using a smartphone. Two neurologists and 2 neuroradiologists performed evaluation of the images using WhatsApp. The gold standard was set by 2 experienced neuroradiologists who evaluated the CT images with their full radiological equipment. Statistical analysis included the calculation of Cohen kappa (κ). RESULTS A total of 104 brain images (derived from 81 patients) were included. All 4 raters performed with a perfect (κ=1) interobserver reliability in diagnosing intracerebral hemorrhage. For subarachnoid hemorrhage, interobserver reliability was slightly lower (raters 1, 2, and 3, κ=1; rater 4, κ=0.88). For diagnosing stroke mimics, interobserver reliability showed considerable variations (κ between 0.32 and 1). Alberta Stroke Program Early CT Score differences overall were comparable between raters and did not exceed 3 to 4 points without noticeable outliers. All raters performed with a moderate-to-substantial interobserver reliability for detecting large vessel occlusions (κ=0.48 in rater 1, κ=0.62 in rater 2, and κ=0.63 in raters 3 and 4). CONCLUSIONS Stroke neurologists can reliably extract information on intracerebral hemorrhage from CT images recorded via smartphone and sent through instant messaging tools. Remote diagnosis of early infarct signs and stroke mimics was less reliable. We developed a standard for the acquisition of images, taking data protection into account.
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Affiliation(s)
- Love-Preet Kalra
- Department of Neurology, Goethe University Frankfurt, Germany. (L.-P.K., C.F.)
| | - Himani Khatter
- Department of Neurology, Christian Medical College, Ludhiana, India. (H.K., A.K., R.S., J.D.P.)
| | - Anirudh Kulkarni
- Department of Neurology, Christian Medical College, Ludhiana, India. (H.K., A.K., R.S., J.D.P.)
| | - Rajeshwar Sahonta
- Department of Neurology, Christian Medical College, Ludhiana, India. (H.K., A.K., R.S., J.D.P.)
| | - Shubhra Rathore
- Department of Radiology, Christian Medical College, Ludhiana, India. (S.R.)
| | - Elke Hattingen
- Department of Neuroradiology, Goethe University Frankfurt, Germany. (E.H., S.-J.Y., M.W., S.W., F.K.)
| | - Se-Jong You
- Department of Neuroradiology, Goethe University Frankfurt, Germany. (E.H., S.-J.Y., M.W., S.W., F.K.)
| | - Marlies Wagner
- Department of Neuroradiology, Goethe University Frankfurt, Germany. (E.H., S.-J.Y., M.W., S.W., F.K.)
| | - Stefan Weidauer
- Department of Neuroradiology, Goethe University Frankfurt, Germany. (E.H., S.-J.Y., M.W., S.W., F.K.)
| | - Fee Keil
- Department of Neuroradiology, Goethe University Frankfurt, Germany. (E.H., S.-J.Y., M.W., S.W., F.K.)
| | - Jeyaraj Durai Pandian
- Department of Neurology, Christian Medical College, Ludhiana, India. (H.K., A.K., R.S., J.D.P.)
| | - Christian Foerch
- Department of Neurology, Goethe University Frankfurt, Germany. (L.-P.K., C.F.)
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Sebastian I, Kate MP, Khatter H, Singh B, Pandian JD. Spectrum of Cardiovascular Autonomic Dysfunction and 24-hour Blood Pressure Variability in Idiopathic Parkinson's Disease. Ann Indian Acad Neurol 2022; 25:902-908. [PMID: 36561008 PMCID: PMC9764881 DOI: 10.4103/aian.aian_289_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/15/2022] [Accepted: 06/20/2022] [Indexed: 12/25/2022] Open
Abstract
Background Uncertainty prevails regarding the patterns of autonomic dysfunction in patients with idiopathic Parkinson's disease (IPD). This study was undertaken with the aim of assessing the complete spectrum of cardiovascular autonomic function tests (CAFTs) and blood pressure variability patterns in IPD patients while comparing the same with age-matched controls. Methods Patients with IPD presenting to the Christian Medical College and Hospital from December 2016 to November 2018 along with age-matched controls were prospectively evaluated using CAFTs. The IPD patients also underwent ambulatory blood pressure (BP) monitoring (ABPM), and the diurnal systolic BP differences were used to classify into dippers (10-20%), non-dippers (0-10%), reverse dippers (<0%), and extreme dippers (>20%). Results Autonomic dysfunction (AD) was prevalent in 41 (68.3%) IPD patients even in early disease (median (inter-quartile range) symptom duration 2 (1-4) years, mean Hoehn and Yahr (H&Y) stage 2 (1.5-2.8). Both sympathetic and parasympathetic parameters were impaired among IPD patients when compared to healthy controls. (E: I ratio 1.17 ± 0.12 vs 1.26 ± 0.14 (P < 0.001), Valsalva ratio (VR) 1.33 ± 0.27 vs 1.55 ± 0.25 (P < 0.001), PRT100 9.6 ± 8.0 vs 3.1 ± 1.8 (P < 0.001), tilt-up SBPAvg change 8.8 (4.2-13.8) vs 1.8 (-2.9-6.1) (P < 0.001), tilt-up HRAvg change 4.8 (2.2-8.2) vs 1.9 (-0.7-5.1) (P < 0.001). BP variability was demonstrated in 47 (79.7%) of IPD patients, with reverse dipping pattern in 28 (47.5%) seen more frequently in this cohort. Conclusions Timely detection of AD may be helpful not only in recognizing IPD in its pre-motor stages but also in optimizing management for this population of patients. BP variability and abnormal dipping patterns on ABPM can be a potential marker of dysautonomia.
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Affiliation(s)
- Ivy Sebastian
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Mahesh P. Kate
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Himani Khatter
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Bharat Singh
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Jeyaraj D. Pandian
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India,Address for correspondence: Dr. Jeyaraj D. Pandian, Professor and Principal, Department of Neurology, Christian Medical College and Hospital, Ludhiana - 141 008, Punjab, India. E-mail:
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Pandian J, Singh S, Jaison V, Khatter H, Adya S, Singh B. Establishment of normative data for autonomic function tests in indian population. Ann Indian Acad Neurol 2022; 25:457-463. [PMID: 35936597 PMCID: PMC9350810 DOI: 10.4103/aian.aian_579_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/20/2021] [Accepted: 11/06/2021] [Indexed: 11/11/2022] Open
Abstract
Background: Normative data for autonomic function tests (AFT) is not available for Indian population. Objective: The aim of the study was to establish normative data in AFT and its correlation with age, gender, and body mass index. Material and Methods: The study was done on 254 healthy subjects of age ≥18 years. All AFTs were done in autonomic laboratory at the Department of Neurology, Christian Medical College and Hospital, Ludhiana. Cardiovascular tests (heart rate response to deep breathing, HR changes in Valsalva maneuver and head-up tilt test (HUT)) and quantitative sudomotor axon reflex testing (QSART) were performed in all the subjects. Fifty subjects underwent thermoregulatory sweat test (TST). Results: The mean age (SD) of study participants was 43 (16.0) years (range 20–84), and 129 (50.8%) were men. The normative value range (2.5–97.5 percentile) for HR difference, E: I ratio, and Valsalva ratio (VR) was 3.5–47.0, 1.05–1.93, and 1.11–2.64, respectively, for all the subjects. HR difference and E: I ratio showed an significant inverse relation with age (r = -0.623 and r = -0.584, respectively). VR also showed an inverse relation with age (r = -0.575, P =< 0.001), and female had a lower value than male (1.63 vs 1.78, P =< 0.001). In QSART, mean (SD) sweat volume was higher in males 0.630 (0.230) compared to females 0.513 (0.132) for all sites, P < 0.001, and similar trend was noticed for sweat area in TST. Discussion and Conclusion: Normative AFT data has been established for Indian population for the first time. The values are comparable to previously published studies.
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Kalra LP, Khatter H, Ramanathan S, Sapehia S, Devi K, Kaliyaperumal A, Bal D, Sebastian I, Kakarla R, Singhania A, Rathore S, Klinsing S, Pandian JD, Foerch C. Serum GFAP for stroke diagnosis in regions with limited access to brain imaging (BE FAST India). Eur Stroke J 2021; 6:176-184. [PMID: 34414293 PMCID: PMC8370074 DOI: 10.1177/23969873211010069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/19/2021] [Indexed: 12/28/2022] Open
Abstract
Introduction Despite a high burden of stroke, access to rapid brain imaging is limited in many middle- and low-income countries. Previous studies have described the astroglial protein GFAP (glial fibrillary acidic protein) as a biomarker of intracerebral hemorrhage. The aim of this study was to test the diagnostic accuracy of GFAP for ruling out intracranial hemorrhage in a prospective cohort of Indian stroke patients. Patients and methods This study was conducted in an Indian tertiary hospital (Christian Medical College, Ludhiana). Patients with symptoms suggestive of acute stroke admitted within 12 h of symptom onset were enrolled. Blood samples were collected at hospital admission. Single Molecule Array technology was used for determining serum GFAP concentrations. Results A total number of 155 patients were included (70 intracranial hemorrhage, 75 ischemic stroke, 10 stroke mimics). GFAP serum concentrations were elevated in intracranial hemorrhage patients compared to ischemic stroke patients [median (interquartile range) 2.36 µg/L (0.61–7.16) vs. 0.18 µg/L (0.11–0.38), p < 0.001]. Stroke mimics patients had a median GFAP serum level of 0.14 µg/L (0.09–0.26). GFAP values below the cut-off of 0.33 µg/L (area under the curve 0.871) ruled out intracranial hemorrhage with a negative predictive value of 89.7%, (at a sensitivity for detecting intracranial hemorrhage of 90.0%). Discussion The high negative predictive value of a GFAP test system allows ruling out patients with intracranial hemorrhage. Conclusion In settings where immediate brain imaging is not available, this would enable to implement secondary prevention (e.g., aspirin) in suspected ischemic stroke patients as soon as possible.
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Affiliation(s)
- Love-Preet Kalra
- Department of Neurology, Goethe-University, Frankfurt am Main, Germany
| | - Himani Khatter
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | | | - Sameer Sapehia
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Kavita Devi
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | | | - Deepti Bal
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Ivy Sebastian
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Raviteja Kakarla
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Anusha Singhania
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Shubhra Rathore
- Department of Radiology, Christian Medical College, Ludhiana, Punjab, India
| | - Svenja Klinsing
- Department of Neurology, Goethe-University, Frankfurt am Main, Germany
| | | | - Christian Foerch
- Department of Neurology, Goethe-University, Frankfurt am Main, Germany
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Pandian JD, Verma SJ, Arora D, Sharma M, Dhaliwal R, Khatter H, Huilgol R, Sylaja PN, Dhasan A, Renjith V, Pathak A, Pai A, Sharma A, Vaishnav A, Ray B, Khurana D, Mittal G, Kulkarni G, Sebastian I, Roy J, Kumaravelu S, John L, Kate M, Srivastava MV, Kempegowda MB, Borah N, Ramrakhiani N, Rai N, Ojha P, Bhatia R, Das R, Sureshbabu S, Jabeen SA, Bhoi S, Aaron S, Sarma P, Saroja AO, Abraham S, Sharma S, Sulena S, Gorthi S, Nagarjunakonda S, Narayan S, Mathew T, George T, Vijaya P, Huded V, Nambiar V, Reddy YM. INSTRuCT: Protocol, Infrastructure, and Governance. Stroke 2021; 52:e574-e580. [PMID: 34167324 DOI: 10.1161/strokeaha.120.033149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Very few large scale multicentric stroke clinical trials have been done in India. The Indian Council of Medical Research funded INSTRuCT (Indian Stroke Clinical Trial Network) as a task force project with the objectives to establish a state-of-the-art stroke clinical trial network and to conduct pharmacological and nonpharmacological stroke clinical trials relevant to the nation and globally. The purpose of the article is to enumerate the structure of multicentric stroke network, with emphasis on its scope, challenges and expectations in India. METHODS Multiple expert group meetings were conducted by Indian Council of Medical Research to understand the scope of network to perform stroke clinical trials in the country. Established stroke centers with annual volume of 200 patients with stroke with prior experience of conducting clinical trials were included. Central coordinating center, standard operating procedures, data and safety monitoring board were formed. DISCUSSION In first phase, 2 trials were initiated namely, SPRINT (Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in India) and Ayurveda treatment in the rehabilitation of patients with ischemic stroke in India (RESTORE [Rehabilitation of Ischemic stroke Patients in India: A Randomized controlled trial]). In second phase, 4 trials have been approved. SPRINT trial was the first to be initiated. SPRINT trial randomized first patient on April 28, 2018; recruited 3048 patients with an average of 128.5 per month so far. The first follow-up was completed on May 27, 2019. RESTORE trial randomized first patient on May 22, 2019; recruited 49 patients with an average of 3.7 per month so far. The first follow-up was completed on August 30, 2019. CONCLUSIONS In next 5 years, INSTRuCT will be able to complete high-quality large scale stroke trials which are relevant globally. REGISTRATION URL: http://www.ctri.nic.in/; Unique Identifier: CTRI/2017/05/008507.
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Affiliation(s)
- Jeyaraj Durai Pandian
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India. (J.D.P., S.J.V., D.A., H.K., R.H., M.K.)
| | - Shweta Jain Verma
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India. (J.D.P., S.J.V., D.A., H.K., R.H., M.K.)
| | - Deepti Arora
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India. (J.D.P., S.J.V., D.A., H.K., R.H., M.K.)
| | - Meenakshi Sharma
- Non-Communicable Diseases Section, Indian Council of Medical Research, New Delhi, India (M.S., R. Dhaliwal)
| | - Rupinder Dhaliwal
- Non-Communicable Diseases Section, Indian Council of Medical Research, New Delhi, India (M.S., R. Dhaliwal)
| | - Himani Khatter
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India. (J.D.P., S.J.V., D.A., H.K., R.H., M.K.)
| | - Rahul Huilgol
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India. (J.D.P., S.J.V., D.A., H.K., R.H., M.K.)
| | - P N Sylaja
- Department of Neurology, Sri Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. (P.N.S., A.D., V.R.)
| | - Aneesh Dhasan
- Department of Neurology, Sri Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. (P.N.S., A.D., V.R.)
| | - Vishnu Renjith
- Department of Neurology, Sri Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. (P.N.S., A.D., V.R.)
| | - Abhishek Pathak
- Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India (A. Pathak)
| | - Aparna Pai
- Department of Neurology, Kasturba Medical College and Hospital, Manipal, Karnataka, India (A. Pai, S.G.)
| | - Arvind Sharma
- Department of Neurology, Zydus Hospital, Ahmedabad, Gujarat, India (A.S.)
| | - Anand Vaishnav
- Vadodara Institute of Neurosciences, Vadodara, Gujarat, India (A.V.)
| | - Biman Ray
- Bangur Institute of Neurosciences, Kolkata, India (B.R.)
| | - Dheeraj Khurana
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India (D.K.)
| | - Gaurav Mittal
- Department of Neurology, St Stephens Hospital, Delhi, India (G.M., I.S., S. Sureshbabu)
| | - Girish Kulkarni
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India (G.K.)
| | - Ivy Sebastian
- Department of Neurology, St Stephens Hospital, Delhi, India (G.M., I.S., S. Sureshbabu)
| | - Jayanta Roy
- Department of Neurology, Institute of Neurosciences, Kolkata, West Bengal, India (J.R.)
| | | | - Lydia John
- Department of Medicine, Baptist Christian Hospital, Tezpur, Assam, India (L.J., S. Abraham)
| | - Mahesh Kate
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India. (J.D.P., S.J.V., D.A., H.K., R.H., M.K.)
| | - M V Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India (M.V.S., R.B.)
| | | | - Nomal Borah
- Department of Neurology, Guwahati Neurological Research Centre, Dispur, India (N.B., R. Das)
| | - Neetu Ramrakhiani
- Department of Neurology, Fortis Escorts Hospital, Jaipur, Rajasthan, India (N. Ramrakhiani)
| | - Nirendra Rai
- Department of Neurology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India (N. Rai)
| | - Pawan Ojha
- Department of Neurology, Grant Government Medical College and Sir J.J. Group of Hospitals College, Mumbai, India (P.O.)
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India (M.V.S., R.B.)
| | - Rupjyoti Das
- Department of Neurology, Guwahati Neurological Research Centre, Dispur, India (N.B., R. Das)
| | - Sachin Sureshbabu
- Department of Neurology, St Stephens Hospital, Delhi, India (G.M., I.S., S. Sureshbabu)
| | - Shaikh Afshan Jabeen
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India (S.A.J.)
| | - Sanjeev Bhoi
- Department of Neurology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India (S.B.,)
| | - Sanjith Aaron
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India (S. Aaron, T.G.)
| | - Prabhakaran Sarma
- Achutha Menon Center for Health Science Studies, Sri Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. (P.S.)
| | | | - Sherly Abraham
- Department of Medicine, Baptist Christian Hospital, Tezpur, Assam, India (L.J., S. Abraham)
| | - Sudhir Sharma
- Department of Neurology, Indira Gandhi Medical College & Hospital, Shimla, Himachal Pradesh, India (S. Sharma)
| | - Sulena Sulena
- Department of Neurology, GGS Medical College, Faridkot, Punjab, India (S. Sulena)
| | - Sankar Gorthi
- Department of Neurology, Kasturba Medical College and Hospital, Manipal, Karnataka, India (A. Pai, S.G.)
| | | | - Sunil Narayan
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India (S. Narayan)
| | - Thomas Mathew
- Department of Neurology, St John's Medical College, Bangalore, Karnataka, India (T.M.)
| | - Tina George
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India (S. Aaron, T.G.)
| | - Pamidimukkala Vijaya
- Department of Neurology, Lalitha Super Speciality Hospital, Guntur, Andhra Pradesh, India (P.V.)
| | - Vikram Huded
- Department of Neurology, Mazumdar Shaw Medical Centre, Narayana Hrudayalaya, Bangalore, Karnataka, India (V.H.)
| | - Vivek Nambiar
- Department of Neurology, Amrita Institute of Medical Sciences, Kochi, Kerala, India (V.N.)
| | - Y Muralidhar Reddy
- Department of Neurology, CARE Hospital, Hyderabad, Telangana, India (M.R.)
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9
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Gandhi DB, Kamalakannan S, Chockalingam M, Sebastian IA, Urimubenshi G, Alim M, Khatter H, Chakraborty S, Solomon JM. Expert consensus for in-hospital neurorehabilitation during the COVID-19 pandemic in low- and middle-income countries. Wellcome Open Res 2021; 6:130. [PMID: 35118197 PMCID: PMC8787554 DOI: 10.12688/wellcomeopenres.16715.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 11/20/2022] Open
Abstract
Background: People with neurological dysfunction have been significantly affected by the ongoing coronavirus disease 2019 (COVID-19) crisis in receiving adequate and quality rehabilitation services. There are no clear guidelines or recommendations for rehabilitation providers in dealing with patients with neurological dysfunction during a pandemic situation especially in low- and middle-income countries. The objective of this paper was to develop consensus-based expert recommendations for in-hospital based neurorehabilitation during the COVID-19 pandemic for low- and middle-income countries based on available evidence. Methods: A group of experts in neurorehabilitation consisting of neurologists, physiotherapists and occupational therapists were identified for the consensus groups. A scoping review was conducted to identify existing evidence and recommendations for neurorehabilitation during COVID-19. Specific statements with level 2b evidence from studies identified were developed. These statements were circulated to 13 experts for consensus. The statements that received ≥80% agreement were grouped in different themes and the recommendations were developed. Results: 75 statements for expert consensus were generated. 72 statements received consensus from 13 experts. These statements were thematically grouped as recommendations for neurorehabilitation service providers, patients, formal and informal caregivers of affected individuals, rehabilitation service organizations, and administrators. Conclusions: The development of this consensus statement is of fundamental significance to neurological rehabilitation service providers and people living with neurological disabilities. It is crucial that governments, health systems, clinicians and stakeholders involved in upholding the standard of neurorehabilitation practice in low- and middle-income countries consider conversion of the consensus statement to minimum standard requirements within the context of the pandemic as well as for the future.
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Affiliation(s)
- Dorcas B.C. Gandhi
- College of Physiotherapy and Department of Neurology, Christian Medical College, Ludhiana, Punjab, 141008, India
| | | | - Manigandan Chockalingam
- Occupational Therapy, School of Health Sciences, National University of Ireland, Galway, Galway, H91 TK33, Ireland
| | - Ivy A. Sebastian
- Department of Neurology, St. Stephen’s Hospital, New Delhi, New Delhi, 110054, India
| | - Gerard Urimubenshi
- Department of Physiotherapy, School of Health Sciences, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Mohammed Alim
- Stroke Clinical Trials Group, Cumming School of Medicine, Calgary, Alberta, T2N 1N4, Canada
| | - Himani Khatter
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, 141008, India
| | - Stuti Chakraborty
- Department of Physical Medicine and Rehabilitation, Christian Medical College, Vellore, Vellore, Tamil Nadu, 632002, India
| | - John M. Solomon
- Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
- Centre for Comprehensive Stroke Rehabilitation and Research, Manipal Academy of Higher Education, Manipal, Karnataka, 567104, India
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10
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Singh S, Kate M, Samuel C, Kamra D, Kaliyaperumal A, Nandi J, Khatter H, Sharma M, Pandian J. Rural Stroke Surveillance and Establishment of Acute Stroke Care Pathway Using Frontline Health Workers in Rural Northwest India: The Ludhiana Experience. Neuroepidemiology 2021; 55:297-305. [PMID: 33951647 DOI: 10.1159/000515636] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE The role of community health workers (CHWs) in stroke surveillance and in establishing the stroke care pathway has not been studied. The aim of the study was to evaluate the feasibility of using CHWs in the public health system to identify stroke patients for population-based stroke registration and to study the establishment of acute stroke care pathway in rural areas of Ludhiana, Punjab, Northwest India. METHODS Two rural blocks in Ludhiana district, comprising 164 villages and a population of 259,778, were selected. Phase-1 (feasibility study) was from August to November 2016 and phase-2 from December 2016 to November 2018. All first-ever stroke cases in adults (aged ≥18 years) were included. The accredited social health activists (ASHAs) were trained to identify stroke patients in the community, who were later evaluated by a neurologist. Stroke characteristics were recorded, and the outcome was assessed at 6 months using modified Rankin scale (0-2, good outcome). FINDINGS During phase-2, 359 first-ever stroke patients and 102 stroke mimics were identified. The age-standardized incidence rate was 218.5/100,000 and 197∙6/100,000 for each year. Half (52.4%) of the patients reached health-care facilities within 4.5 h, yet none of them received thrombolysis. Very few patients (1.9%) utilized free government 108 ambulance service to reach a health-care facility. Out of 359 stroke cases, the majority (306, 85.23%) were reported by ASHAs and 14.77% were reported by other sources. Brain imaging was available in 127 (35.4%) patients, and 100 (78.7%) had ischemic stroke. The most common risk factor was hypertension (320, 89%) and drug abuse (154, 42.9%). At 6 months, 168 (64%) patients had a good outcome. CONCLUSION ASHAs were able to identify stroke patients in the villages. Despite high numbers of patients reaching health-care facilities within a window period, the hospitals were unable to provide acute stroke treatment like thrombolysis. The health-care system needs to be strengthened to improve stroke care.
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Affiliation(s)
- Shavinder Singh
- Department of Community Medicine, Christian Medical College and Hospital, Ludhiana, India
| | - Mahesh Kate
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Clarence Samuel
- Department of Community Medicine, Christian Medical College and Hospital, Ludhiana, India
| | - Deepshikha Kamra
- Department of Community Medicine, Christian Medical College and Hospital, Ludhiana, India
| | | | - Jayshree Nandi
- Department of Community Medicine, Christian Medical College and Hospital, Ludhiana, India
| | - Himani Khatter
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
| | | | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
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11
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John L, William A, Dawar D, Khatter H, Singh P, Andrias A, Mochahari C, Langhorne P, Pandian J. Implementation of a Physician-Based Stroke Unit in a Remote Hospital of North-East India-Tezpur Model. J Neurosci Rural Pract 2021; 12:356-361. [PMID: 33927525 PMCID: PMC8064833 DOI: 10.1055/s-0041-1723099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective
The study aims to determine the effects of implementing stroke unit (SU) care in a remote hospital in North-East India.
Materials and Methods
This before-and-after implementation study was performed at the Baptist Christian Mission Hospital, Tezpur, Assam between January 2015 and December 2017. Before the implementation of stroke unit care (pre-SU), we collected information on usual stroke care and 1-month outcome of 125 consecutive stroke admissions. Staff was then trained in the delivery of SU care for 1 month, and the same information was collected in a second (post-SU) cohort of 125 patients.
Statistical Analysis
Chi-square and Mann–Whitney U test were used to compare group differences. The loss to follow-up was imputed by using multiple imputations using the Markov Chain Monto Carlo method. The sensitivity analysis was also performed by using propensity score matching of the groups for baseline stroke severity (National Institute of Health Stroke Scale) using the nearest neighbor approach to control for confounding, and missing values were imputed by using multiple imputations. The adjusted odds ratio was calculated in univariate and multivariate regression analysis after adjusting for baseline variables. All the analysis was done by using SPSS, version 21.0., IBM Corp and R version 4.0.0., Armonk, New York, United States.
Results
The pre-SU and post-SU groups were age and gender matched. The post-SU group showed higher rates of swallow assessment (36.8 vs. 0%,
p
< 0.001), mobility assessment, and re-education (100 vs. 91.5%,
p
= 0.037). The post-SU group also showed reduced complications (28 vs. 45%,
p
= 0.006) and a shorter length of hospital stay (4 ± 2.16 vs. 5 ± 2.68 days,
p
= 0.026). The functional outcome (modified ranking scale) at 1-month showed no difference between the groups, good outcome in post-SU (39.6%) versus pre-SU (35.7%),
p
= 0.552.
Conclusion
The implementation of this physician-based SU care model in a remote hospital in India shows improvements in quality measures, complications, and possibly patient outcomes.
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Affiliation(s)
- Lydia John
- Department of Medicine, Baptist Christian Hospital, Tezpur, Assam, India
| | - Akanksha William
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Dimple Dawar
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Himani Khatter
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Pratibha Singh
- Department of Medicine, Baptist Christian Hospital, Tezpur, Assam, India
| | - Anjana Andrias
- Department of Medicine, Baptist Christian Hospital, Tezpur, Assam, India
| | | | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, Royal Infirmary Hospital, Glasgow, United Kingdom
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
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12
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Kate M, Jaison V, Sharma S, Khatter H, Calton R, Pandian J. Cognitive impairment in patients with atrial fibrillation without stroke. CHRISMED J Health Res 2021. [DOI: 10.4103/cjhr.cjhr_81_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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Ahmad L, Kapoor P, Bhaskar S, Khatter H. Screening of obstructive sleep apnea (OSA) risk in adolescent population and study of association with craniofacial and upper airway morphology. J Oral Biol Craniofac Res 2020; 10:807-813. [PMID: 33224724 DOI: 10.1016/j.jobcr.2020.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/09/2020] [Accepted: 10/10/2020] [Indexed: 12/19/2022] Open
Abstract
Background Obstructive sleep apnea (OSA) is a common form of sleep-disordered breathing with high prevalence and associated co-morbidities. It still goes largely under-reported due to events occurring in sleep and difficulty in identifying predisposing factors. Aims To perform questionnaire-based screening of OSA-risk in adolescents and study association of OSA-risk with craniofacial and upper airway morphology. Material and methods Modified STOP-BANG questionnaire was used for screening OSA-risk in adolescent orthodontic patients (10-19 years) in a government dental hospital in India. Patients were categorised into two groups: OSA-risk and non-risk, based on the questionnaire scores, and were subsequently evaluated for craniofacial and upper airway morphology, both on examination and on lateral cephalometric radiographs. Results Documented a high prevalence of 14% for OSA-risk in adolescent orthodontic patients. The extra-oral and intra-oral parameters found significantly associated with OSA-risk were convex profile [Odd's ratio (OR) - 3.824], steep mandibular plane angle [MPA] (OR- 79.75), Type 3/4 faucial pillars (OR- 11.227), Class II molar relationship (OR - 4.518), ovoid upper arch form (OR - 13.750). In addition, the cephalometric parameters: ANB (p- 0.025), SN-MP (p- 0.007), BA-SN (p- 0.020), PNS-AD1 (p < 0.001), PNS-AD2 (p - 0.001) also showed highly significant association to OSA-risk. The ROC curves demonstrated high sensitivity and specificity for PNS-AD1 (60%,83.3%), PNS-AD2 (73.3%, 70%) and SN-MP (60%,70%), respectively for OSA-risk. Conclusions The study supported applicability of modified STOP-BANG questionnaire for OSA-risk in Indian adolescents. The parameters [extra-oral, intra-oral, cephalometric and upper airway (PNS-AD1, PNS-AD2, SN-MP)] significantly associated with OSA-risk, were identified.
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Affiliation(s)
- Lubna Ahmad
- Intern, Faculty of Dentistry, Jamia Millia Islamia, New Delhi, 110025, India
| | - Priyanka Kapoor
- Professor, Department of Orthodontics & Dentofacial Orthopedics, Faculty of Dentistry, Jamia Millia Islamia, New Delhi, 110025, India
| | - Sejal Bhaskar
- Final Year Student, Faculty of Dentistry, Jamia Millia Islamia, New Delhi, 110025, India
| | - Himani Khatter
- Biostatistician, Dept of Neurology, Christian Medical College & Hospital, Ludhiana, 141008, India
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14
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Gandhi DB, Sterba A, Khatter H, Pandian JD. Mirror Therapy in Stroke Rehabilitation: Current Perspectives. Ther Clin Risk Manag 2020; 16:75-85. [PMID: 32103968 PMCID: PMC7012218 DOI: 10.2147/tcrm.s206883] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/16/2020] [Indexed: 12/30/2022] Open
Abstract
In contrast to varied therapy approaches, mirror therapy (MT) can be used even in completely plegic stroke survivors, as it uses visual stimuli for producing a desired response in the affected limb. MT has been studied to have effects not just on motor impairments but also on sensations, visuospatial neglect, and pain after stroke. This paper attempts to systematically review and present the current perspectives on mirror therapy and its application in stroke rehabilitation, and dosage, feasibility and acceptability in stroke rehabilitation. An electronic database search across Google, PubMed, Web of Science, etc., generated 3871 results. After screening them based on the inclusion and exclusion criteria, we included 28 studies in this review. The data collected were divided on the basis of application in stroke rehabilitation, modes of intervention delivery, and types of control and outcome assessment. We found that most studies intervened for upper limb motor impairments post stroke. Studies were equally distributed between intervention in chronic and acute phases post stroke with therapy durations lasting between 1 and 8 weeks. MT showed definitive motor and sensory improvements although the extent of improvements in sensory impairments and hemineglect is limited. MT proves to be an effective and feasible approach to rehabilitate post-stroke survivors in the acute, sub-acute, and chronic phases of stroke, although its long-term effects and impact on activities of daily living need to be analysed extensively.
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Affiliation(s)
- Dorcas Bc Gandhi
- College of Physiotherapy, Christian Medical College & Hospital Ludhiana, Ludhiana, Punjab, India.,Faculty of Medicine, Masaryk University, Stroke Brno, International Clinical Research Center, St. Anne´s University Hospital, Brno, Czech Republic
| | - Albert Sterba
- Department of Neurology, Christian Medical College & Hospital Ludhiana, Ludhiana, Punjab, India
| | - Himani Khatter
- Faculty of Medicine, Masaryk University, Stroke Brno, International Clinical Research Center, St. Anne´s University Hospital, Brno, Czech Republic
| | - Jeyaraj D Pandian
- Faculty of Medicine, Masaryk University, Stroke Brno, International Clinical Research Center, St. Anne´s University Hospital, Brno, Czech Republic
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15
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Venugopalan VY, Bhatia R, Pandian J, Khurana D, Kaul S, Sylaja PN, Arora D, Khatter H, Padma MV, Singhal AB. Regional differences in ischemic stroke in India (north vs. south). Int J Stroke 2019; 14:706-714. [PMID: 30702415 DOI: 10.1177/1747493019828538] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND India is a large country with geographically diverse populations and varying risk factors. Identification of regional differences can improve healthcare policy decisions. AIM To study regional differences in stroke between North and South India. METHODS We analyzed data from the Indo-US Collaborative Stroke Project, a National Institute of Health-funded multicentre prospective study conducted in five academic centers in India with a US-based coordinating center. Risk factors, severity, mechanisms, management, complications, and outcomes among ischemic stroke patients were compared between North and South Indian centers. RESULTS Of the 2066 patients enrolled from North (n = 1060) and South India (n = 1006), North Indian patients were significantly older with fewer men and had lower rates of diabetes (32.8% vs. 38.7%, p < 0.01), dyslipidemia (3.5% vs. 25.7%, p < 0.01), tobacco use (27% vs. 38%, p < 0.001), and alcohol use (30.1% vs. 38.6%, p < 0.01). North Indian patients had higher median National Institute of Health stroke scale scores (10 vs. 9, p < 0.01), more frequent large-artery atherosclerosis mechanism (34% vs. 25.6%, p < 0.001), intravenous thrombolysis (14.0% vs. 6.1%, p < 0.001), and lower rates of pneumonia (10.5% vs. 15.1%, p = 0.02). The three-month outcome (modified Rankin Scale score 0-2, 45.8% vs. 50.3%, p = 0.08) did not differ; however, North Indian patients had higher 90-day mortality (23.5% vs. 13.5%, p < 0.0001). CONCLUSIONS The substantial regional differences in stroke risk factors and mechanisms may be partly explained by factors such as differing dietary habits and lifestyle, which can be addressed at a national level. Differences in acute and inpatient stroke care suggest a need for better adoption of national stroke management guidelines.
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Affiliation(s)
- Vishnu Y Venugopalan
- Department of Neurology, All-India Institutes of Medical Sciences, New Delhi, India
| | - Rohit Bhatia
- Department of Neurology, All-India Institutes of Medical Sciences, New Delhi, India
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
| | - Dheeraj Khurana
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subhash Kaul
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - P N Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Deepti Arora
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
| | - Himani Khatter
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
| | - M V Padma
- Department of Neurology, All-India Institutes of Medical Sciences, New Delhi, India
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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