International Journal of Stroke - Volume 14, Number 8

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Editorial
Restricted accessEditorialFirst published October, 2019pp. 761-762
Reducing the burden of stroke: Opportunities and mechanisms
Valery FeiginORCIDMichael Brainin
Editorial
Restricted accessEditorialFirst published October, 2019pp. 763-765
Implementing the SRRR taskforce recommendations to transform stroke recovery research
Kate HolmesDale CorbettSharon McGowan
Research article
Restricted accessResearch articleFirst published October, 2019pp. 766-773
Moving stroke rehabilitation research evidence into clinical practice: Consensus-based core recommendations from the Stroke Recovery and Rehabilitation Roundtable
Janice J EngORCIDMarie-Louise BirdErin GodeckeORCID
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Abstract
Moving research evidence to practice can take years, if not decades, which denies stroke patients and families from receiving the best care. We present the results of an international consensus process prioritizing what research evidence to implement into stroke rehabilitation practice to have maximal impact. An international 10-member Knowledge Translation Working Group collaborated over a six-month period via videoconferences and a two-day face-to-face meeting. The process was informed from surveys received from 112 consumers/family members and 502 health care providers in over 28 countries, as well as from an international advisory of 20 representatives from 13 countries. From this consensus process, five of the nine identified priorities relate to service delivery (interdisciplinary care, screening and assessment, clinical practice guidelines, intensity, family support) and are generally feasible to implement or improve upon today. Readily available website resources are identified to help health care providers harness the necessary means to implement existing knowledge and solutions to improve service delivery. The remaining four priorities relate to system issues (access to services, transitions in care) and resources (equipment/technology, staffing) and are acknowledged to be more difficult to implement. We recommend that health care providers, managers, and organizations determine whether the priorities we identified are gaps in their local practice, and if so, consider implementation solutions to address them to improve the quality of lives of people living with stroke.
Research article
Restricted accessResearch articleFirst published October, 2019pp. 774-782
Cognition in stroke rehabilitation and recovery research: Consensus-based core recommendations from the second Stroke Recovery and Rehabilitation Roundtable
Matthew W McDonaldORCIDSandra E BlackDavid A Copland
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Abstract
Cognitive impairment is an important target for rehabilitation as it is common following stroke, is associated with reduced quality of life and interferes with motor and other types of recovery interventions. Cognitive function following stroke was identified as an important, but relatively neglected area during the first Stroke Recovery and Rehabilitation Roundtable (SRRR I), leading to a Cognition Working Group being convened as part of SRRR II. There is currently insufficient evidence to build consensus on specific approaches to cognitive rehabilitation. However, we present recommendations on the integration of cognitive assessments into stroke recovery studies generally and define priorities for ongoing and future research for stroke recovery and rehabilitation. A number of promising interventions are ready to be taken forward to trials to tackle the gap in evidence for cognitive rehabilitation. However, to accelerate progress requires that we coordinate efforts to tackle multiple gaps along the whole translational pathway.
Research article
Restricted accessResearch articleFirst published October, 2019pp. 783-791
Standardized measurement of quality of upper limb movement after stroke: Consensus-based core recommendations from the Second Stroke Recovery and Rehabilitation Roundtable
G KwakkelORCIDEEH Van WegenJH Burridge
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Abstract
The second Stroke Recovery and Rehabilitation Roundtable “metrics” task force developed consensus around the recognized need to add kinematic and kinetic movement quantification to its core recommendations for standardized measurements of sensorimotor recovery in stroke trials. Specifically, we focused on measurement of the quality of upper limb movement. We agreed that the recommended protocols for measurement should be conceptually rigorous, reliable, valid and responsive to change. The recommended measurement protocols include four performance assays (i.e. 2D planar reaching, finger individuation, grip strength, and precision grip at body function level) and one functional task (3D drinking task at activity level) that address body function and activity respectively. This document describes the criteria for assessment and makes recommendations about the type of technology that should be used for reliable and valid movement capture. Standardization of kinematic measurement protocols will allow pooling of participant data across sites, thereby increasing sample size aiding meta-analyses of published trials, more detailed exploration of recovery profiles, the generation of new research questions with testable hypotheses, and development of new treatment approaches focused on impairment. We urge the clinical and research community to consider adopting these recommendations.
Research article
Restricted accessResearch articleFirst published October, 2019pp. 792-802
A stroke recovery trial development framework: Consensus-based core recommendations from the Second Stroke Recovery and Rehabilitation Roundtable
Julie BernhardtKathryn S HaywardORCIDNuma Dancause
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Abstract
A major goal of the Stroke Recovery and Rehabilitation Roundtable (SRRR) is to accelerate development of effective treatments to enhance stroke recovery beyond that expected to occur spontaneously or with current approaches. In this paper, we describe key issues for the next generation of stroke recovery treatment trials and present the Stroke Recovery and Rehabilitation Roundtable Trials Development Framework (SRRR-TDF). An exemplar (an upper limb recovery trial) is presented to demonstrate the utility of this framework to guide the GO, NO-GO decision-making process in trial development.
Meeting report
Restricted accessMeeting reportFirst published October, 2019pp. 803-805
How can the World Stroke Organization (WSO) optimize education in stroke medicine around the world? Report of the 2018 WSO Global Stroke Stakeholder Workshop
Gord GubitzORCIDMonica SainiORCIDSarah Belson
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Abstract
Background
Education in stroke is relevant to stroke survivors, clinicians, care providers, and healthcare system administrators and is of special importance in resource-limited settings. The World Stroke Organization Education Committee undertook a program of work, culminating in a focused workshop, to establish the key educational priorities, and work toward maximizing the WSOs impact on the global burden of stroke.
Methods
A facilitated workshop took place during the World Stroke Congress in Montreal, Canada in October 2018. The workshop was developed using opinions on priority topics for World Stroke Organization educational activities obtained from web-based surveys of World Stroke Organization Members, supplemented by interviews with international stroke support organizations. The workshop included over 50 international participants, selected to represent a balance of age, gender, geographical region, and different levels of health resources. Participants also included members of the World Stroke Organization Education Committee, the World Stroke Academy, stroke support organizations, and the International Journal of Stroke editorial board. The workshop focused on understanding more about educational needs (at all levels), with emphasis on resource-limited settings.

Three broad questions were posed: (1) What are the key educational needs: (a) in your region, (b) from your perspective (e.g. stroke support organization)? (2) Do the current educational activities offered by World Stroke Organization and WSA meet your needs? (3) What could World Stroke Organization/World Stroke Academy offer in your region that would meet your needs? The facilitated discussions were recorded, and the results transcribed and summarized by members of the World Stroke Organization Education Committee.
Results
Five key needs were identified:

1. Collaborative interdisciplinary, training in both stroke care and how to advocate for stroke.

2. Educational materials provided in a wider range of formats that could be adapted to local circumstances and clinical practices.

3. Educational activities for healthcare providers and stroke support organizations organized regionally, with the World Stroke Organization providing organizational support, and a pool of experts, therapists, nurses, etc. to deliver locally relevant materials.

4. Clear and authoritative online resources, where it is easy to find key policy and protocol guidance.

5. A range of online interactive education and training resources to help build knowledge and competence in stroke care.
Conclusion
The results of the workshop have been presented to the World Stroke Organization Board and will be used to help to guide the educational initiatives of the World Stroke Organization and World Stroke Academy going forward.
Meeting report
Restricted accessMeeting reportFirst published October, 2019pp. 806-817
World Stroke Organization (WSO): Global Stroke Fact Sheet 2019
M Patrice LindsayORCIDBo NorrvingRalph L Sacco
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Review article
Restricted accessReview articleFirst published October, 2019pp. 818-825
Multi-level community interventions for primary stroke prevention: A conceptual approach by the World Stroke Organization
Michael BraininValery FeiginORCIDPhilip M BathORCID
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Abstract
The increasing burden of stroke and dementia emphasizes the need for new, well-tolerated and cost-effective primary prevention strategies that can reduce the risks of stroke and dementia worldwide, and specifically in low- and middle-income countries (LMICs).

This paper outlines conceptual frameworks of three primary stroke prevention strategies: (a) the “polypill” strategy; (b) a “population-wide” strategy; and (c) a “motivational population-wide” strategy.

(a) A polypill containing generic low-dose ingredients of blood pressure and lipid-lowering medications (e.g. candesartan 16 mg, amlodipine 2.5 mg, and rosuvastatin 10 mg) seems a safe and cost-effective approach for primary prevention of stroke and dementia.

(b) A population-wide strategy reducing cardiovascular risk factors in the whole population, regardless of the level of risk is the most effective primary prevention strategy. A motivational population-wide strategy for the modification of health behaviors (e.g. smoking, diet, physical activity) should be based on the principles of cognitive behavioral therapy. Mobile technologies, such as smartphones, offer an ideal interface for behavioral interventions (e.g. Stroke Riskometer app) even in LMICs.

(c) Community health workers can improve the maintenance of lifestyle changes as well as the adherence to medication, especially in resource poor areas. An adequate training of community health workers is a key point.
Conclusion
An effective primary stroke prevention strategy on a global scale should integrate pharmacological (polypill) and lifestyle modifications (motivational population-wide strategy) interventions. Side effects of such an integrative approach are expected to be minimal and the benefits among individuals at low-to-moderate risk of stroke could be significant. In the future, pragmatic field trials will provide more evidence.
Research article
Restricted accessResearch articleFirst published October, 2019pp. 826-834
Sex differences in stroke metrics among Southeast Asian countries: Results from the Global Burden of Disease Study 2015
Wen Yea HwongORCIDMichiel L BotsSharmini Selvarajah
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Abstract
Background
Sex differences in cardiovascular diseases generally disadvantage women, particularly within developing regions.
Aims
This study aims to examine sex-related differences in stroke metrics across Southeast Asia in 2015. Furthermore, relative changes between sexes are compared from 1990 to 2015.
Methods
Data were sourced from the Global Burden of Disease Study. Incidence and mortality from ischemic and hemorrhagic strokes were explored with the following statistics derived: (1) women-to-men incidence/mortality ratio and (2) relative percentage change in rate.
Results
Women had lower incidence and mortality from stroke compared to men. Notable findings include higher ischemic stroke incidence for women at 30–34 years in high-income countries (women-to-men ratio: 1.3, 95% CI: 0.1, 16.2 in Brunei and 1.3, 95% CI: 0.5, 3.2 in Singapore) and the largest difference between sexes for ischemic stroke mortality in Vietnam and Myanmar across most ages. Within the last 25 years, greater reductions for ischemic stroke metrics were observed among women compared to men. Nevertheless, women below 40 years in some countries showed an increase in ischemic stroke incidence between 0.5% and 11.4%, whereas in men, a decline from −4.2% to −44.2%. Indonesia reported the largest difference between sexes for ischemic stroke mortality; a reduction for women whereas an increase in men. For hemorrhagic stroke, findings were similar: higher incidence among young women in high-income countries and greater reductions for stroke metrics in women than men over the last 25 years.
Conclusions
Distinct sex-specific differences observed across Southeast Asia should be accounted in future stroke preventive guidelines.
Research article
Open accessResearch articleFirst published October, 2019pp. 835-842
A national economic and clinical model for ischemic stroke care development in Saudi Arabia: A call for change
Fahmi Al-SenaniMohammed Al-JohaniMohammad Salawati
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Abstract
Background
Stroke is a significant burden in Saudi Arabia and the Saudi Ministry of Health's stroke committee has identified an urgent need to improve care.
Aim
The purpose of this study was to undertake a health-economic analysis to quantify the impact of developing stroke care in the country.
Methods
An economic model was developed to assess the costs and clinical outcomes associated with an ischemic stroke care development program compared with current stroke care. Based on Saudi epidemiological data, cohorts of ischemic stroke patients enter the model each year for the first 10 years based on increasing incidence. Four treatment options were modeled including reperfusion and non-reperfusion treatments. The development scenario estimates the impact of gradually increasing uptake of more effective treatments over 10 years. Changes in the stroke care organization are considered along with resources required to increase capacity, allowing more patients to be admitted to stroke hospitals and access effective treatments.
Results
The stroke care development program is associated with an increase in functionally independent patients and a decrease in disabling strokes compared with current stroke care. Additionally, the development program is associated with estimated cost savings of $602 million over 15 years ($255 million direct costs, $348 million indirect costs).
Conclusions
The model predicts that the stroke care development program is associated with improved patient outcomes and lower overall costs compared with the current stroke care program.
Research article
Restricted accessResearch articleFirst published October, 2019pp. 843-849
Top 10 global educational topics in stroke: A survey by the World Stroke Organization
Monica SainiORCIDSarah BelsonCarmen Lahiff-Jenkins
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Abstract
Aim
As part of a program of work to develop an educational strategy and implementation plan for the World Stroke Organization, we conducted a survey of World Stroke Organization members (health professionals, laypersons (Stroke Support Organizations)) to identify their potential educational needs.
Methods
We developed a questionnaire to identify priority educational needs in consultation with the World Stroke Organization Education Committee. The World Stroke Organization invited all individual members and associated Stroke Support Organizations to complete the questionnaire via a web-based survey. Survey responses were supplemented by questionnaires emailed directly to key persons in Stroke Support Organizations and information from semi-structured telephone interviews, where necessary. The questionnaire asked respondents to prioritize topics in diagnosis, management of acute stroke, stroke care services, stroke rehabilitation, and stroke prevention. Free-text responses were assessed with word cloud.
Results
The online survey was completed by 264 respondents from 60 countries; 19.1% were from low- and middle-income countries, 59% were stroke specialist physicians, 28% allied health professionals or nurses, 9% Stroke Support Organizations, 4% general physicians. Fifteen Stroke Support Organizations from 11 countries responded to the emailed survey. Seven Stroke Support Organizations' members were interviewed by telephone; one was interviewed in-person. We highlight the two highest priority topics in each of the five questionnaire domains.
Conclusion
The 10 priority topics were all applicable in a low- or middle-income setting: setting up and delivering stroke diagnosis, treatment, rehabilitation and prevention services, and emphasized the most basic elements of care. The survey participants have identified a number of key topics that merit inclusion in stroke teaching materials and courses, especially those aimed at practitioners working in resource-limited settings.

Volume 14, Issue 8, October 2019