Prevalence of Stroke in Kingdom of Saudi Arabia-Through a Physiotherapist Diary

In Saudi Arabia, according to statistics, cardiovascular disease amounts to a major cause of deaths each year. Current data on stroke in the Kingdom of Saudi Arabia are lacking. This study is a national survey to inform decision-makers on the current magnitude of the epidemic. The data obtained for this study is from the nationwide physiotherapy departments that provide rehabilitative treatments to stroke patients. The study also tries to systematically analyze the published prevalence of many international countries and have tried to compare it with the available data of stroke prevalence in Saudi Arabia. The results shown in this study do make us understand that it is still not late to bring in preventive actions against stroke in Saudi Arabia.


Introduction 1.
"Health care is an increasing concern" is the usual paragraph starter of any health related journal paper written in GCC country.Be that the McKinsey report by Mourshed et al., 2010, or Algazy, 2009or Klautzer et al., 2014, each of these papers constantly remind about the health care problems to be envisaged in Gulf Countries.It may seem biased to call a Country to be "very high in coronary heart diseases" (Klautzer et al., 2014), and for researchers to predict that GCC will have an exponential growth in the number of lifestyle diseases in the coming future.This paper would rely heavily on the McKinsey report that projects treatment demand in GCC by 2025.Over the next 20 years, treatment demand will rise in the GCC by 240 percent.It is also expected that in particular, cardiovascular disease will experience a steep increase (419 percent), as will diabetes-related ailments (323 percent).But most of these projections are made generic, for example, cardio vascular, infectious disease, maternal and perinatal disease, and digestive and genitourinary diseases etc. Keeping this statistics in mind this research is an attempt to find out the total cases of Stroke patients in Kingdom of Saudi Arabia, one that would help in deep probing of the problem at hand.
The Kingdom of Saudi Arabia (KSA) is the largest country in the Middle East.It occupies approximately four-fifths of the Arabian Peninsula constituting a population of more than 28 million.In Saudi Arabia, according to statistics, cardiovascular disease amounts for 22 percent of deaths each year (Ashirwatham and Zamzam, 2014).Current data on stroke in the Kingdom of Saudi Arabia are lacking.We conducted a national survey to inform decision-makers on the current magnitude of the epidemic.Stroke, otherwise called hemiplegia is caused due to blood clots or embolus which travels in the systemic circulation suddenly blocks the arteries of the brain leading to paralysis of the opposite side of the body being supplied by the brain, if the right side of the brain is affected, the left side of the body becomes paralyzed and vice versa, it is a cerebrovascular accident ultimately due to ischemic changes or lack of blood flow.Stroke is increasingly emerging as a major health problem, in Middle East region (Tran et al., 2010).In a study by Kamran et al., 2007 reported that a major percentage of the patients had not even heard the term "stroke" in the Gulf Cooperation Council (GCC) countries.The study made an alarming find that the knowledge regarding stroke was poorest among the groups that belonged to the highest risk bracket for stroke, as per the study.Studies have looked into the cause factors of stroke in Middle East region and have attributed old age, high blood pressure, prior stroke or Transient Ischemic Attack (TIA), diabetes, high cholesterol, tobacco smoking and atrial fibrillation as the major risk factors for stroke (Robert and Zamzami, 2014).Studies have proved that a person with diabetes, blood pressure, or high cholesterol is more at risk for a stroke (Awada and Al Rajeh, 1999).A lot of factors that increase the risk of a stroke includes obesity, smoking, sedentary lifestyle, etc.Even gender differences of stroke in Saudi Arabia are studied and research indicates that prevalence of stroke among men than women (Yaqub et al., 1991).
Stroke can leave an individual with a residual damage of physical, psychological, social and cognitive functions, depending on tand severity of the epidemic.In another study by Al Kathaami et al., 2011 who interviewed neurologists about their views on stroke, reports that acute stroke care in Saudi Arabia as inadequate.Al Rajeh et al., 1993, who studied about 500 consecutive patients with first-ever stroke admitted in a hospital that exclusively serves the Saudi Arabian National Guard community suggested that stroke incidence is low in Saudi Arabia compared with industrialized countries.They presume that it would be because of the predominance of young age groups in the country.Their study held that overall distribution of stroke types was closer to that of Western populations than to the Japanese, in whom hemorrhagic strokes were highly prevalent at that time.Ever since 1993 there has been an increase in the number of stroke patients in Saudi Arabia.Akbar et al., (2001) showed that stroke was more frequent in the sixth decade of life with male predominance in both Saudis and non-Saudis, a finding similar to what has been reported by others (Al Jishi and Mohan 1999, Awada and Al Rajeh, 1999).This might be a reason to start a nationwide survey on the prevalence of the epidemic.
Research has shown that the Middle East region faces a double burden of the disease due to decreasing rates of communicable diseases and the growing rates of non-communicable diseases (Robert and Zamzami, 2014;Akala and El-Saharty, 2006).Quari ( 2000) conducted a study among stroke patients who were admitted at King Abdul Aziz University Hospital and found that there was a high incidence of thrombotic stroke in their study.In 2012 a study was conducted by Al Aqueel et al., who reported an alarming deficit in the level of stroke awareness in the Saudi population.Urgent public health measures to correct this deficiency, which will match the rate of similar countries, was also suggested to be implied.
The overall literature survey points that there is a dearth of stroke data in physiotherapy departments and rehabilitation centres in Saudi Arabia.Research studies available on stroke cases in physiotherapy deals with trials, experiments and interventions.One study has looked into the characteristics which are most associated with free-living and lack of physical activity in community-dwelling ambulatory people after stroke, but the respondent size was too low i.e, 18 cases (Alzharani et al., 2011).Such studies would not be able to bring about the real size of stroke epidemic in the country.
Review of published literature available on stroke in Middle East region points out that they are either projections or is specific to particular regions of Saudi Arabia.This paper is one of a kind in itself that we have conducted a national level survey in order to find out the prevalence of Stroke cases in the whole Kingdom from a physiotherapist perspective.The data has the number of stroke cases present in physiotherapy departments in each of the region of the Kingdom.Such a data can help the policy makers to take actions to start organising nation-wide stroke care and to further up on the existing evidence-practice gap as reported by many researchers.The lack of stroke related research especially in physiotherapy makes this paper unique.The objective of this study is to provide primafacea information about stroke prevalence, since all the cases are referred post stroke attack.

3.
The methodology used in this study is counting method, cases still alive on the desired prevalence date are simply counted, since it is the most common method used in studying prevalence.The data of total stroke cases in the whole of Saudi Arabia in the year 2012-2013 is collected.The total number of population in Saudi Arabia is 27 million, including nearly 8.5 million expatriates (2010 census).The provinces of Saudi Arabia are divided as follows.The prevalence of stroke in KSA is more difficult to estimate accurately.A prevalence of 178/100,000 was reported in a community based survey from the Eastern region of KSA (Awada andAl Rajeh, 2002, Awada, 2011).Overall, the incidence and prevalence of stroke in KSA appears to be lower than the rates in the Western countries but falls within the range observed among Asian populations (Ayoola, 2003).

Period Prevalence Rate of Stroke according to the data in Saudi 4.
By using the formula, Period prevalence = Number of cases occurred in a given period/ no of people in the given population during this period X 100 According to American Heart Association, 2015 "Prevalence is an estimate of how many people have a specific disease, condition or risk factor at a given point in time.These rates are applied as the population changes for several years, until a new health examination survey is done and new rates are established".It's important to realize that the prevalence rates do not change from year to year until there is a new survey.There is a dearth of nationwide data availability on stroke in the KSA.Where as in Libya, the incidence rates for hemorrhagic stroke were 2.7 per 100 000.Saudi Arabia showed 1.9 per 100 000 stroke incidence, and 10.4 per 100 000 in Iran.Wasay, Khatri and Kaul SAARC 2013 The estimated annual incidence of stroke in Pakistan was found to be 250 per 100,000 population.It is also projected that an estimate of 350,000 new cases will increase every year.Sri Lanka, with its population of about 20 million, has an estimated stroke prevalence of 9 per 1,0000 population.Lack of empirical data from Afghanistan, Nepal, Bhutan and Maldives, makes it difficult to analyze.Data from India concludes that the incidence and prevalence of stroke in this region is higher than in the USA and China.
Centers for disease control and prevention 2013 USA The prevalence of CHD/stroke among all adults aged <55 years was estimated to be 2.8%.This includes both CHD with 2.0% for coronary heart disease and stroke showing 1.0% rate.The prevalence among employed adults was found to be 1.9%.
From the data, it can be understood that prior studies in Middle East were accurate indeed in establishing, that the stroke epidemic in the region is lesser than that of Asia, USA and China.This study also reveals that among the regions of Saudi, Qunfuthah, Al Hassa, Jazan and Quassim are leaning towards higher prevalence for stroke.In a similar study by Ayoola et al., 2003, collected data on patients with stroke admitted to King Fahd Central Hospital, Jizan, KSA over a 2year period from January 1997 to December 1998, and found the crude incidence (estimated as 15.9 per 100, 000) in Jizan, KSA.The researchers concluded that a national stroke registry should be strengthened to provide further information on the epidemiology of stroke in KSA.
From the study, it can be concluded that in Saudi Arabia, the prevalence of strokes is low when compared with those recorded in the Western and Asian countries.This could be due to the predominance of the younger age groups in this region.There is a need to monitor the food habits and life style of the youngsters in the country so that the stroke epidemic can be kept in check.This research brings out the fact that Saudi Arabia is still not higher in stroke epidemic and this epidemic can be controlled in the country provided more proactive screening and diagnosis can be made.Despite the food habits, money and any associated reason for stroke prediction in the GCC, Saudi Arabia can still be called healthy when it comes to stroke.

Table 1 :
List of available Literature in the Kingdom:RiyadhLiterature Review Lack of nationwide, research in establishing the incidence and prevalence of strokes in Saudi Arabia in recent years.Available literature points out that the crude incidence rate for first-ever incidence of stroke in Saudi Arabia was 29.8/100,000/year., spanned 10 years and 7 months, is one of the largest cohort of children with stroke at one medical centre worldwide available in Saudi Arabia.Among the study group of 104 Saudi children, ischemic stroke accounted for the majority of cases (82%), whereas intracranial hemorrhage was less common (18%).
GizanEmpirical Study The crude incidence (estimated as 15.9 per 100, 000) in Gizan, KSA, a largely rural area is lower than the reported rates in urban areas of KSA.Alaqeel et al., 2012 RiyadhEmpirical study Of the respondents, 2862 completed the questionnaire.Out of which, 1844 (64%) were able to define stroke correctly.1428 (49.9%) named mass media as the source of their knowledge about stroke.The study concluded that many in SA do have knowledge about Stroke.

Table 2 :
The 13 provinces and city population and cases of stroke

Table 3 :
Period Prevalence Rate of Stroke

Table 4 :
Crude Prevalence of stroke worldwide -Available Literature