Physiotherapists play a key role in stroke centres and in effective rehab services, says Commission

Much provision is of a 'low intensity' globally

Members of the commission gathered information by conducting interviews in-depth interviews with stroke experts around the world. They learned that most stroke rehabilitation efforts are currently focused on ‘a small range of services, for a limited time, and in only some settings’.

‘Respondents stated that often only physiotherapy was available, with very little access to other specialties (eg, speech therapy, occupational therapy, and neuropsychology). Publicly funded rehabilitation services were mostly provided with acute care, and not in the community or patients’ homes, or via telemedicine approaches.’

As well as the extremely patchy nature of provision, much of that offered is ‘low intensity’ in nature – ‘delivering interventions to patients at too low a frequency or too short a duration, or not offering therapies that are engaging, challenging, and of sufficiently high quality’.

This pattern could explain the contrasting recovery patterns in patients in low to middle income countries (LMICs) compared with those living in high income countries (HICs). ‘The provision of simple interventions, including education of patients about their self-management, was recorded in 29 (35 per cent) of the 84 countries included in the World Stroke Organization survey,’ the authors note.

Awareness increasing in some regions

Respondents detected a ‘low awareness of the role of rehabilitation after stroke across a broad range of stakeholders’– in the community and among healthcare professionals and policymakers, for example.

This lack of awareness resulted in ‘low political will’ to fund services and little advocacy to increase access to, or the scope of, services. On a more positive note, the authors state: ‘However, some shifts in awareness, particularly among healthcare professionals, linked to the growing evidence base and professionalisation of the allied health workforce, were reported in countries with trained therapists across several regions.’

'Telemedicine and telerehabilitation’ options

The authors suggest that ‘telemedicine and telerehabilitation’ might offer solutions to the poor availability and low uptake of rehabilitation but offer a caveat. ‘Though telerehabilitation is viewed positively by both healthcare staff and patients with stroke when offered in a research setting, there can be challenges with equipment set-up, the scope of exercises that can be counselled on is restricted, and there are difficulties with patient assessment, interface problems, and time constraints.’

In addition, some healthcare professionals may lack the time to offer telerehabilitation assistance, in addition to their other duties in a clinical setting. ‘Further investigations into the feasibility, safety, efficacy, and cost-effectiveness of telerehabilitation in different regions are needed,’ the authors state.

Stroke exerts an enormous toll on the world’s population, leading to the death and permanent disability of millions of people each year, and costing billions of dollars [Valery L Feigin]

Long waiting times for assessment and intervention

Too often, poor service organisation and a lack of protocols for rehabilitation in LMICs and some HICs leads to prolonged waiting times before people’s individual needs are assessed and responded to.

Many are discharged from hospital without a rehabilitation plan being in place (a major requirement in discharge schemes), with ‘inadequate long-term support, inadequate screening and care for depression, and little psychological and social support.

Unless urgent action is taken, the number of people who die from stroke globally could increase by half by 2050 – amounting to 9.7 million deaths annually.

More stroke centres needed

The Commission calls for more the creation of more stroke centres, staffed by multidisciplinary teams. 'We recommend the establishment of advanced stroke centres, with at least one centre per 2 million people. The multidisciplinary team should include at least a physician, a nurse, a nurse assistant, a physiotherapist, and a speech therapist.'

What did the Commission do?

The commission’s findings are based on a review of evidence-based guidelines, recent surveys, and in-depth interviews. As well as offering recommendations to reduce the global burden of stroke, it recommends steps that will improve stroke surveillance, prevention, acute care and rehabilitation.

Auckland University of Technology-based Professor Valery L Feigin, a Commission co-chair, said: ‘Stroke exerts an enormous toll on the world’s population, leading to the death and permanent disability of millions of people each year, and costing billions of dollars.

'Precisely forecasting the health and economic impacts of stroke decades into the future is inherently challenging given the levels of uncertainty involved, but these estimates are indicative of the ever-increasing burden we will see in the years ahead unless urgent, effective action is taken.’

Key recommendations include 

• establish low-cost surveillance systems to provide accurate epidemiological stroke data to guide prevention and treatment
• raise public awareness and action to improve healthy lifestyles and prevent stroke through population-wide use of mobile and digital technologies, such as training and awareness-raising videos and apps
• prioritise effective planning of acute stroke care services, capacity building, training, provision of appropriate equipment, treatment and affordable medicines, and adequate resource allocation at national and regional levels.
• adapt evidence-based recommendations to regional contexts, including training, and support and supervision of community health workers to assist in long-term stroke care.
• establish local, national, and regional ecosystems involving all relevant stakeholders to co-create, co-implement and monitor stroke surveillance, prevention, acute care, and rehabilitation

The number of people who suffer a stroke, die from, or remain disabled by the condition globally has almost doubled over the past 30 years, with the vast majority of those affected in LMICs, where prevalence of the condition is increasing at a faster rate than in HICs. Economic analysis indicates treatment, rehabilitation, and indirect costs of stroke could more than double from US$891 billion in 2020 to up to US$2.3 trillion in 2050.

Professor Mayowa O Owolabi, from the University of Ibadan, Nigeria and Commission co-chair, said: ‘Investing in evidence-based measures to reduce the global burden of stroke will deliver benefits that go far beyond health alone.'

Professor Owolabi added: 'As well as delivering health and economic benefits relating to stroke, many of our recommendations would also facilitate reductions in poverty and inequality and boost local economies.’

To access the article – titled Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization–Lancet Neurology Commission – click