Evidence-based stroke rehabilitation: do priorities for practice change and feasibility of implementation vary across high income, upper and lower-middle income countries?

PURPOSE: The context of implementation plays an important role in the delivery of optimal treatments in stroke recovery and rehabilitation. Considering that stroke systems of care vary widely across the globe, the goal of the present paper is to compare healthcare providers' priority of key areas in translating stroke research to clinical practice among High Income Countries, Upper Middle- and Lower Middle-Income Countries (HICs, UMICs, LMICs). We also aimed to compare perceptions regarding the key areas' feasibility of implementation, and formulate recommendations specific to each socioeconomic region. METHODS: Data related to recommendations for knowledge translation in stroke, from a primary survey from the second Stroke Recovery and Rehabilitation Roundtable were segregated based on socioeconomic region. Frequency distribution was used to compare the key areas for practice change and examine the perceived feasibility of implementation of the same across HIC, UMIC and LMICs. RESULTS: A total of 632 responses from healthcare providers across 28 countries were received. Interdisciplinary care and access to services were high priorities across the three groups. Transitions in Care and Intensity of Practice were high priority areas in HICs, whereas Clinical Practice Guidelines were a high priority in LMICs. Interventions specific to clinical discipline, screening and assessment were among the most feasible areas in HICs, whereas Intensity of practice and Clinical Practice Guidelines were perceived as most feasible to implement in LMICs. CONCLUSION: We have identified healthcare providers' priorities for addressing international practice change across socioeconomic regions. By focusing on the most feasible key areas, we can aid the channeling of appropriate resources to bridge the disparities in stroke outcomes across HICs, UMICs and LMICs.IMPLICATIONS FOR REHABILITATIONIt is pertinent to examine the differences in priorities of stroke rehabilitation professionals and the feasibility of implementing evidence-based practice across socioeconomic regions.There is an urgent necessity for the development of clinical practice guidelines for stroke rehabilitation in Low-Middle Income Countries, taking into consideration the cultural, economic and geographical constraints.In upper-middle income countries, encouraging family support and timely screening and assessment for aphasia, cognition and depression appear to be the low hanging fruits to enhance quality of life after stroke.Innovative ways to increase intensity of practice and channelling of resources to improve transitions in care may prove to be the most beneficial in advancing stroke rehabilitation in high income countries.

Post-stroke gait training practices in a low resource setting: a cross-sectional survey among Indian physiotherapists.

BACKGROUND: Independent mobility is the most important determinant of quality of life after stroke and it is vital that training aimed at restoration of gait is based on contemporary evidence. Despite several practice guidelines for gait rehabilitation after stroke existing globally, their feasibility of application in low-resource settings is often questionable. OBJECTIVE: To investigate the current practices in gait training among Indian physiotherapists involved in the rehabilitation of stroke survivors. METHODS: A questionnaire on the various aspects of gait training was developed and the content was validated by experts. The survey was made available online and distributed among Indian physiotherapists working in the field of stroke rehabilitation, using snowball sampling. Frequency distribution was used to summarize responses to each component of the questionnaire. RESULTS: Responses were obtained from 250 practicing physiotherapists. The majority of the respondents (55%) reported that they initiate gait training within seven days after stroke. Gait training sessions ranged from 15-30 minutes (55%), once every day (44%), and the majority (89%) reported use of subjective outcome measures to evaluate gait. Although most respondents agreed on the use of assistive aids, 24% indicated that their use may deter gait, rather than improve it. Nearly 86% of the respondents reported that they do not follow standard guidelines pertaining to gait rehabilitation for stroke survivors. CONCLUSION: The findings of the study point toward a lack of evidence-based practice among Indian physiotherapists while training gait after stroke. This implied the urgent need for development and implementation of country specific guidelines for stroke rehabilitation.

Effects of game-based rehabilitation on upper limb function in adults within the first six months following stroke: protocol for a systematic review and meta-analysis.

OBJECTIVE: To evaluate and summarize the level of evidence for the immediate, short-term, and long-term effects of game-based rehabilitation on upper limb function in adults within the first six months following stroke. INTRODUCTION: A game-based intervention is a valuable therapeutic tool for incorporating principles of motor learning and neuroplasticity in the rehabilitation of upper limb function post-stroke. Most of the existing reviews on game-based rehabilitation are focused on the chronic phase of stroke. However, as maximum upper limb motor recovery occurs in the first six months after stroke, further exploration of the effects of game-based rehabilitation in this phase is necessary. INCLUSION CRITERIA: We will include randomized clinical trials assessing the immediate, short-term, and long-term effects of game-based rehabilitation on upper limb function in adults within the first six months following stroke. METHODS: The systematic review will follow the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) checklist and JBI methodology for systematic reviews of effectiveness. A database-specific search strategy will be used in CINAHL, PubMed, Scopus, Web of Science, ProQuest, PEDro, OT Seeker, and Ovid MEDLINE to identify studies in the English language with no date limit. Two reviewers will independently screen, extract data from, and assess risk of bias in the eligible studies. Meta-analysis and publication bias evaluation will be done when adequate data are available. If a meta-analysis is precluded, then a narrative synthesis will be done. The Grading of Recommendations Assessment Development and Evaluation (GRADE) criteria will be used to assess the certainty of evidence for the outcome measures of interest. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42020190100.

Gait training interventions for patients with stroke in India: A systematic review.

BACKGROUND: Gait is considered to be the most important determinant of functional independence in activities of daily living. The challenges faced by stroke survivors in India differ from the western population due to economic, cultural, and geographical factors and this, in turn, may influence the choice of intervention. Hence, there is a need to understand the current gait training trends for stroke survivors in low resource settings like India. RESEARCH QUESTION: To systematically review the literature on interventional strategies for improving gait among stroke survivors in India. METHODS: Six databases were searched to identify RCTs delivering gait training to stroke survivors having some gait deficits in terms of speed or any other kinematic parameters. Studies of the English language from India were included. Two independent reviewers screened, extracted data, and assessed the study quality. A descriptive synthesis was undertaken and the data was summarized. RESULTS: Of 2112 potentially relevant articles, 12 studies with a total of 412 participants were included after title, abstract and full-text screening. Studies tested the efficacy of interventions such as mirror therapy, motor imagery, transcutaneous electrical nerve stimulation, strengthening, and task-based training. The outcome measures were kinematic gait-analysis, gait velocity, Functional Ambulation Categories, Timed Up and Go, Fugl-Meyer Assessment. From the results of this review, active task-based gait training and strengthening along with motor priming seems to be the most tested interventions. Future studies may need to design interventions targeting both impairment and function to bring about maximum improvement in gait after stroke. SIGNIFICANCE: Reviews addressing gait practices in developing countries for people with stroke are scarce. The present review would assist physiotherapists in developing countries to utilize evidence-based criteria for the selection of gait training approaches post-stroke. Due to the environmental and contextual demands, the effect of interventions for recovery among stroke survivors should be improvised in low resource settings. This review can be a source of recommendation in giving effective strategies for clinical practice.