Burden of Stroke: Indian Perspective

Abstract:

In recent years economic and demographic transitions in India have resulted in shift to lifestyle-related chronic diseases like stroke, ischemic heart disease (IHD), diabetes and cancer. In the year 2005, India accounted for more than 53% of all deaths and 44% of disability adjusted life years (DALYs) lost from chronic diseases including stroke; without successful intervention, this is estimated to increase by 18% in the next 10 years. Furthermore, by 2016 an estimated US$ 84 billion of national income will be lost, in middle and low income countries, from chronic diseases alone. To reduce burden of disease in general, World Health Organization (WHO) has proposed a global goal, to reduce chronic disease mortality by 2% per year, over and above what will be achieved by routine intervention; and this is likely to avert 6.4 million deaths from stroke by 2015. However, there is paucity of standardized comparable data on stroke epidemiology to design sustainable primary or secondary prevention strategies. On account of scarce resources and high costs, modern stroke-care for timely treatment of acute stroke is beyond the reach of patients in India. Nonetheless, risk factors for stroke are mainly conventional and intervention to reduce exposure to raised blood pressure, diabetes mellitus, smoking, high cholesterol, and physical inactivity, and multidrug strategy will be cost-effective. Health education, low-salt intake, stopping tobacco use, and lifestyle changes may prove effective. Surveillance of cerebrovascular disease (CVD) risk factors and their determinants for intervention and prevention strategies need emphasis. Indian Council of Medical Research has initiated “risk factors surveillance” in populations. In addition, the Government of India has now launched National Rural Health Mission (NRHM) in support of the above objectives. To reduce the burden of disease in developing nations, an integrated approach for prevention (primary and secondary) of chronic diseases and stroke should receive high priority.

Appendix

National Institute of Health Stroke Scale (NIHSS) (Goldstein and Samsa, 1997)

No.	Category	Response (Score)
1A	Consciousness	Alert (0)/Arousable (1)/Obtunded (2)/Unresponsive (3)
1B	Answers to questions	Answers correctly: Both (0)/One (1)/Neither (2)
1C	Commands	Both correctly (0)/One correctly (1)/Neither (2)
2.	Gaze	Normal (0)/Partial palsy (1)/Total palsy (2)
3.	Visual fields	No loss (0)/Partial hemianopsia (1)/Complete (2)/Bilateral (3)
4.	Facial palsy	None (0)/Minor (1)/Partial (2)/Complete (3)
5.	Motor arm a. left, b. right	No drift (0)/Drift <10 s (1)/Falls <10 s (2) No effort against gravity (3)/No movement (4)
6.	Motor leg a. left, b. right	No drift (0)/Drift <10 s (1)/Falls <10 s (2) No effort against gravity (3)/No movement (4)
7.	Ataxia	None (0)/One limb (1)/Two limbs (2)
8.	Sensory	Normal (0)/Mild loss (1)/Severe loss (2)
9.	Language	Normal (0)/Mild (1)/Severe (2)/Mute or global aphasia (3)
10.	Dysarthria	None (0)/Mild (1)/Severe (2)
11.	Extinction	None (0)/Mild (1)/Severe (2)
Total NIHSS Score – (0–42)

1. Source: Goldstein LB, Samsa GP. Stroke.1997; 28(2):307–310
2. NIHSS is a scoring technique defines degree of neurological deficit ranging from none (0), mild (1) or severe (2–4) for eleven categories of neurologic functions. For practical purpose score of 0–5 indicates mild deficit, 6–15 denotes moderate deficit and score of more than 15 is suggestive of severe neurologic deficit

Barthel Index (Sulter et al., 1999)

No.	Category	Response/Score
1.	Feeding	Independent-10/Needs help-5/Inferior-0
2.	Bathing	Independent-5/Inferior-0
3.	Personal toilet	Washes face, combs hair, brushes teeth, shaves-5/Inferior-0
4.	Dressing	Independent-10/Needs help-5/Inferior-0
5.	Bowel control	Able to use enema, no help-10/needs help-5/Inferior-0
6.	Bladder control (Use of device)	No accidents-10/Occasional accidents-5/Inferior-0
7.	Toilet transfers	Independent-10/Needs help-5/Inferior-0
8.	Chair/Bed Transfers	Independent-15/Minimum assistance-10/Able to sit, needs maximum assistance-5/Inferior-0
9.	Ambulation	Independent for 50 yards-15/With help 50 yards-10/Independent with wheelchair-5/Inferior-0
10.	Stair climbing	Independent-10/Needs help-5/Inferior-0

1. Source: Sulter G, Steen C, Keyser JD (1999). Stroke. 30: 1538–1541
2. Barthel Index is a scoring technique that measures patient’s performance in ten activities of daily life and it is considered a reliable disability scale for stroke patients. For clinical evaluation: 76–100 points denote “good function”; 51–75 points denote “moderate disability” and score under 50 denotes “severe disability.” 0 score represents totally dependant bedridden state

Modified Rankin Scale (Sulter et al., 1999)

Category	Score
No symptoms at all	0
No significant disability despite symptoms	1
Slight disability	2
Moderate disability, but able to walk without assistance	3
Moderate disability, but unable to walk without assistance	4
Severe disability	5

1. Source: Sulter G, Steen C, Keyser JD (1999). Stroke. 30:1538–1541
2. Modified Rankin Scale measures independence rather than performance of specific tasks. Scale consists of six grades from 0 to 5; 0 denotes no symptoms and 5 indicates severe disability. For clinical purpose, mild disability range is from 0 to 2; moderate disability ranges from 3 to 4 and 5 indicates severe disability