The functional outcomes of stroke patients who are HIV positive, HIV negative and HIV undiagnosed, following rehabilitation: a descriptive study

Hartley, Tasneem (2017-12)

Thesis (MScPhysio)--Stellenbosch University, 2017.

Thesis

ENGLISH SUMMARY : Background: With the increase in human immunodeficiency virus (HIV) and non-communicable diseases in low to middle-income countries, the rise in HIV-related stroke incidences is becoming a concern. The sub-Saharan region is where the majority of the global HIV population reside. This places an even greater burden on an already strained healthcare system and economy, as HIV-infected people may have an increased chance of stroke and tend to be significantly younger than the conventional stroke population. With the physical and cognitive deficits that may occur due to HIV infection, along with the neurological deficits caused by stroke, this young population now becomes more dependent, increasing the number of unproductive members of society. Hence, it is important to know whether the combination of stroke and HIV further impairs the function of these individuals. Previous studies assessing the function of HIV-infected patients post stroke focused on mortality rather than the morbidity of HIV+ stroke patients. Furthermore, the outcomes measures used to assess their function were global and not specific enough to describe function adequately. Aim: The primary aim of this thesis is to describe the functional outcomes of HIV positive, HIV negative and HIV undiagnosed patients post stroke following inpatient rehabilitation using various outcome measures. Secondary aims include describing demographics, risk factors, length of stay and patient perception. Setting: The Western Cape Rehabilitation Centre (WCRC), situated in Cape Town, South Africa. Study design: A prospective descriptive cohort study. Methods: Approval for conducting the study was obtained from the Committee of Human Research (HREC) at Stellenbosch University (S15/10/232). From July to December 2016, patients who were admitted to the WCRC post stroke were recruited for the study. Written informed consent was obtained from all eligible participants. Data were collected on admission and just prior to discharge, using the Modified Rankin Scale for stroke severity; the Barthel Index and use of assistive devices to assess function in activities of daily living, level of independence and mobility; the Berg Balance Scale and MatScan (pressure mapping) to assess balance. Data on HIV and immune status, demographics, risk factors and length of stay were also collected. The EQ5D was used to assess participant’s perception of health related quality of life. All data were entered into an Excel spreadsheet, coded and analysed. Continuous data including mRS, BI, BBS and pressure mapping were summarised using median and range. Categorical data were represented as proportions and graphically displayed using a histogram. Statistical analysis was performed using STATA version 14.2 (Statacorp, 2015). Association between categorical variables was assessed using the chi-squared or Fisher’s exact test. Differences in distribution of continuous variables over different levels of a categorical variable were evaluated using the Kruskal-Wallis test, and where differences were detected, the Dunn’s test was used for pairwise comparisons. Relationships between patient characteristics and pain and anxiety were evaluated using ordinal logistic regression. The Kaplan-Meier curve was used to describe the length of stay. Statistical significance was assessed at 5%. Results: Out of 54 potential participants, 49 met the inclusion criteria and were recruited; 9 HIV positive (+), 17 HIV negative (-) and 23 HIV undiagnosed participants. The study sample had 51.02% (n = 25) females and 48.98% (n = 24) males. The majority of the sample were mixed race (53.06%, n = 34), 34.69% (n = 17) were of black ethnicity, 10.20% (n = 5) were white and 2.04% (n = 1) were Indian. A significant difference was found with regard to age. The median age for the HIV+ groups was 30 years, and 50 and 51 years for the other groups, respectively (p = 0.0046). The more common risk factors for the HIV- and undiagnosed groups were hypertension and diabetes (p = 0.001 and p = 0.042) respectively. Substance abuse (p = 0.038) and opportunistic infections (p = 0.005) were more prevalent in the HIV+ group. The median CD4 count was 130 (54-883). All groups showed significant improvements in all functional outcome assessments. The HIV+ group had a higher percentage of participants who scored in the higher percentiles for each functional outcome, but no significant results were seen among groups with regard to change in score in stroke severity (mRS p = 0.748), ADLs, independence and mobility (BI p = 0.886; use of assistive devices p = 0. 722) balance and risk of falling (BBS p = 0.4170 and MatScan results). The HIV+ group scored themselves lower than the other groups on the EQ5D VAS scale. This may have been attributed to their age as they were younger and possibly more functionally abled than their older counterparts, but no significant differences were seen among groups (EQ5D p = 0.805). The HIV+ group had a median length of stay of 45 days, while the HIV- and undiagnosed groups stayed for 55 and 53 days respectively. This difference was not statistically significant (p = 0.0671). Conclusion: Even though the HIV+ group was significantly younger and had fewer risk factors, no statistical significant differences were seen with regard to functional outcome. Functional outcome could be affected by a number of variables. In this sample, HIV status did not seem to affect functional outcome negatively. Larger cohorts are required for more generalisable results, to give a better understanding of the functional outcomes of HIV+ stroke patients.

AFRIKAANSE OPSOMMING : Agtergrond: Met die toename in menslike immuniteitsgebreks virus (MIV) en nie-oordraagbare siektes in lae tot middelinkomste lande, word die styging in MIV-verwante beroertes kommerwekkend. Die Sub-Sahara-streek is waar die meerderheid van die wêreldwye MIV-bevolking woon. Dit plaas 'n groter las op 'n reeds belaste gesondheidsorgstelsel en ekonomie aangesien MIV-geïnfekteerde mense 'n groter kans op beroerte kan hê en geneig is om aansienlik jonger te wees as die konvensionele beroerte populasie. Met die fisiese en kognitiewe probleme wat mag voorkom as gevolg van MIV-infeksie, saam met die neurologiese disfunksie wat veroorsaak word deur beroerte, word hierdie jong bevolking nou meer afhanklike en onproduktiewe lede van die samelewing. Daarom is dit belangrik om te weet of die kombinasie van beroerte en MIV verder die funksie van hierdie individue benadeel. Vorige studies wat die funksie van MIV-geïnfekteerde pasiënte na beroerte beskryf, fokus op mortaliteit eerder as die morbiditeit van MIV-positiewe beroerte pasiënte. Meer so, die meet instrumente wat gebruik word om funksie te assesseer was globaal en nie spesifiek genoeg om die funksionele probleme in detail te beskryf nie. Doel: Om die funksionele uitkomste van MIV-positiewe, MIV-negatiewe en MIV-ondiagnoseerde pasiënte, post beroerte, na binne-pasiënt rehabilitasie met behulp van verskeie meet instrumente te beskryf. Sekondêre doelwitte sluit in die beskrywing van demografie, risikofaktore, lengte van verblyf en pasiënt persepsie. Omgewing: Wes-Kaapse Rehabilitasiesentrum (WKRS), geleë in Kaapstad, Suid-Afrika. Studieontwerp: 'n Voornemende beskrywende kohortstudie. Metodes: Goedkeuring vir die uitvoering van die studie is verkry by die Komitee vir Menslike Navorsing van Stellenbosch Universiteit (S15/10/232). Van Julie tot Desember 2016 is pasiënte, post beroerte, wat tot WKRS toegelaat is, gewerf vir die studie. Skriftelike ingeligte toestemming is verkry van alle kwalifiserende deelnemers. Data is ingesamel by toelating en net voor ontslag, met behulp van die Modified Rankin Scale om die erns van beroerte te bepaal; die Barthel-indeks en die gebruik van hulpmiddels om funksies in die daaglikse lewe, vlak van onafhanklikheid en mobiliteit te assesseer; die Berg Balance Scale en MatScan (druk metings) om balans te evalueer. MIV en immuunstatus, demografie, risikofaktore en lengte van verblyf is ook ingesamel. Die EQ5D is gebruik om pasiënt persepsie van hoe hulle gesondheid hulle kwaliteit van hulle lewe beïnvloed te beskryf. Alle data is in 'n Excel-sigblad ingevoer, gekodeer en ontleed. Opeenvolgende data, insluitend mRS, BI, BBS en MatScan (druk metings), is opgesom met behulp van mediane en omvang. Kategoriese data is as proporsies voorgestel en grafies vertoon met behulp van histogramme. Statistiese analise is uitgevoer met behulp van STATA weergawe 14.2 (Statacorp, 2015). Die assosiasie tussen kategoriese veranderlikes is geassesseer met behulp van die chi-kwadraat toets of Fisher’s exact test. Verspreiding van deurlopende veranderlikes oor verskillende vlakke van kategoriese veranderlikes is geëvalueer met behulp van die Kruskal-Wallis toets, en waar die verskille opgespoor is, is die Dunn toets vir tweerigtingvergelykings gebruik. Verhoudings tussen die volgende pasiënt eienskappe naamlik pyn en angs is geëvalueer met behulp van ordinale logistieke regressie. Die Kaplan-Meier-kurwe is gebruik om die lengte van die verblyf te beskryf. Statistiese betekenisvolheid is geassesseer teen 5%. Resultate: Uit 54 potensiële deelnemers het 49 aan die insluitingskriteria voldoen en is gewerf, naamlik 9 MIV-positiewe (+), 17 MIV-negatiewe (-) en 23 MIV-ondiagnoseerde deelnemers. Die studie het 51,2% (n = 25) vroue en 48,98% (n = 24) mans ingesluit. Meerderheid van die deelnemers was van gemengde ras (53.06%, n = 34), 34.69% (n = 17) was swart, 10.20% (n = 5) was wit en 2,04% (n = 1) was Indiër. 'n Beduidende verskil is gevind met betrekking tot ouderdom. Die mediane ouderdom vir die MIV + groepe was 30 jaar en 50 en 51 jaar vir die ander groepe onderskeidelik (p = 0.0046). Die algemene risikofaktore vir die MIV- en ondiagnoseerde groepe was onderskeidelik hipertensie en diabetes (p = 0.001 en p = 0.042). Middelmisbruik (p = 0.038) en opportunistiese infeksies (p = 0.005) was meer algemeen in die MIV +. Die mediaan CD4 telling was 130 (54-883). Alle groepe het beduidende verbeterings in alle funksionele uitkomsmetings getoon. Die MIV+ groep het 'n hoër persentasie deelnemers gehad wat vir elke funksionele uitkoms in die hoër persentiele behaal het, maar daar was geen beduidende resultate tussen groepe met betrekking tot verandering in telling in erns van beroerte nie (mRS p = 0.748), ADL's, onafhanklikheid en mobiliteit (BI: p = 0.886; gebruik van hulpmiddels: p = 0.722) balans en risiko van val (BBS p = 0.4170 en MatScan resultate). Die MIV + groep het hulself laer geëvalueer as die ander groepe op die EQ5D VAS-skaal. Dit kan toegeskryf word aan hul ouderdom aangesien hulle jonger was en moontlik meer funksioneel as hul ouer eweknieë, maar geen beduidende verskille is tussen groepe (EQ5D p = 0,805) gevind nie. Die MIV + groep het 'n mediane hospitalisasie van 45 dae gehad, terwyl die MIV- en ondiagnoseerde groepe onderskeidelik 55 en 53 dae gehospitaliseer was. Hierdie verskil was nie statisties betekenisvol nie (p = 0.0671). Samevatting: Alhoewel die MIV + groep aansienlik jonger was en minder risikofaktore gehad het, is daar geen statisties beduidende verskille met betrekking tot funksionele uitkomste gesien nie. Funksionele uitkomste kan beïnvloed word deur 'n aantal veranderlikes. In hierdie steekproef het MIV-status nie die funksionele uitkomste negatief beïnvloed nie. Groter kohorte word benodig vir meer veralgemeende resultate om 'n beter begrip van die funksionele uitkomste van MIV+ beroerte pasiënte te gee.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/102976
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