Welcome to the WSC 2021 Interactive Program

Background and Aims

Clinical practice guidelines (CPGs) provide an evidence-based foundation to build optimal services for people with stroke. In comparison to High Income Countries where many comprehensive stroke rehabilitation guidelines exist, identifying evidence-based guidelines specific to Low-and-Middle-Income Countries (LMICs) is challenging. This project aims to:

1. Evaluate the quality and content of existing CPGs for Stroke rehabilitation from LMICs

2. Develop LMIC-specific CPGs based on findings identified

Methods

This project will be executed by a multi-disciplinary core team of stroke rehabilitation professionals, through a multi-phased process. An advisory board of global stroke-rehabilitation experts will provide periodic inputs wherever essential.

Phase I: A systematic review on the existing CPGs for stroke rehabilitation from LMICs will be conducted. Quality and methodological rigour of the CPGs will be assessed based on an identified cut-off on AGREE-II and AGREE-REX tools.

Phase II: CPGs which meet the essential criteria in Phase I will be compared for content with the standardized WSO Global services guidelines and action plan, to identify the existing gaps.

Phase III: LMIC-specific stroke rehabilitation CPGs will be developed informed by the merits and demerits identified in previous phases.

Results

Through this project we intend to study the quality and content of CPGs for stroke rehabilitation, identify the existing gaps and develop new evidence-based CPGs specific to LMICs.

Conclusions

There exist wide gaps in the availability as well as implementation of CPGs for stroke rehabilitation in LMICs. This study is designed with the larger objective of identifying those gaps, and developing CPGs specifically tailored to LMICs.

Background and Aims

The reasons people with post-stroke aphasia have poor health outcomes are not well understood. We aimed to determine factors associated with aphasia, and compare the frequency of post-stroke hospital readmissions amongst patients with and without aphasia.

Methods

Patient-level data from the Australian Stroke Clinical Registry (years 2009-2013) were linked to national death data, hospital emergency presentations and admissions data from Victoria, Queensland, New South Wales and Western Australia. Multivariable logistic regression was used to assess factors associated with aphasia identified from ICD10 discharge codes for the index stroke event. Cox regression was used for hospital readmissions within 30 days, 90 days, 180 days and 1-year. Comorbidities were identified using ICD-10 coded admission data from 5-years prior to the stroke event.

Results

12,690 adults with stroke were included (median age 76; 54% male; 77% ischaemic stroke); 26% identified with aphasia. The factors most strongly associated with aphasia were prior diagnosis of stroke (aOR 7.76, 95%CI 2.44-24.7; p<0.001), paraplegia (aOR 1.57, 95%CI 1.42-1.75; p<0.001), and atrial fibrillation (aOR 1.56, 95%CI 1.41-1.73; p<0.001). Compared to people without aphasia, people with aphasia more often had a hospital readmission within 180 days (HR 1.11, 95%CI 1.02-1.22; p=0.009), and 1-year (HR 1.12, 95%CI 1.03-1.21; p=0.005). Hospital readmissions within 30 days and 90 days were not significantly different.

Conclusions

Patients with prior stroke are more likely to experience aphasia following a new stroke event. Early aphasia-specific secondary stroke prevention, education and support may help reduce the prevalence of post-stroke aphasia and hospital readmissions.

Background and Aims

Early and intense motor intervention is thought to yield greater upper limb recovery post-stroke. This systematic review investigated timing, dose and efficacy of upper limb intervention during the first 6-months post-stroke.

Methods

Three databases were searched (PROSPERO:CRD42016048035). Studies that enrolled people ≤6-months post-stroke, aimed to improve upper limb recovery, and completed pre- and post-intervention assessment were included. Studies were examined by timing (recovery epoch), dose and efficacy (minimal clinical important difference, MCID).

Results

261 studies were included, representing 228 (n=9,704 participants) unique datasets. Studies per 5-year interval increased from one (n=37 participants) between 1980-1984 to 91 (n=4,417 participants) between 2015-2019. Participants were enrolled a median 38 days (IQR 22-66) post-stroke. Studies were identified within each recovery epoch: 1 hyperacute, 13 acute, 176 early subacute, 34 late subacute; 4 unable to be categorised. The median intervention and control dose was 45-minutes/session, 1 session/day, 5-days/week for 4-weeks, which was consistent across epochs. For motor impairment, 102 studies contained data to interpret a MCID. In 69% (n=70) of these studies, impairment outcomes were similar (eg. MCID achieved by intervention and control groups). For motor activity, 107 studies contained data to interpret a MCID and 67% (n=72) of activity outcomes were similar.

Conclusions

Despite a large and growing body of research, lack of consistent data elements prevented identification of the optimal timing to commence upper limb intervention post-stroke, and the effect of timing and dose on efficacy. A united research agenda that establishes a biological understanding of timing and dose is needed to progress stroke recovery research.

Background and Aims

Repetitive peripheral sensory stimulation (RPSS) followed by 4-hour task-specific training improves upper limb motor function in subjects with stroke who experience moderate to severe motor upper limb impairments.

Here, we compared effects of RPSS versus sham followed by a shorter duration of training in subjects with moderate to severe motor impairments in the chronic phase after stroke.

Methods

In this single-center, randomized, placebo-controlled, parallel-group clinical trial, we compared effects of 18 sessions of either 1.5 hours of active RPSS or sham followed by a supervised session of 30-minutes of functional electrical stimulation (FES) and 45-minutes of task-specific training (TST) of the paretic upper limb. In both groups, subjects were instructed to perform functional tasks at home, without supervision. The primary outcome measure was the Wolf Motor Function Test (WMFT) after six weeks of treatment. Grasp and pinch strength were secondary outcomes.

Results

In intention-to-treat analysis, WMFT improved significantly in both active and sham groups at 3 and 6 weeks of treatment. Grasp strength improved significantly in the active, but not in the sham group, at 3 and 6 weeks. Pinch strength improved significantly in both groups at 3 weeks, and only in the active group at 6 weeks.

Conclusions

RPSS enhanced hand strength in chronic stroke. Despite the short duration of supervised training (2.75 hours/session), changes in WMFT in both groups were comparable to those reported after longer, more intensive training protocols. These findings are relevant to settings that impose constraints in duration of direct contact between therapists and patients.

Background and Aims

Stroke is often regarded as a disease of the elderly. However, 10-15% of strokes occur in people between ages 18 to 50. Young stroke survivors face unique challenges, such as returning to work or raising children, which may not be fully addressed by current stroke rehabilitation resources. The purpose of our qualitative study is to identify gaps in patient care and resources specific to young stroke survivors, and to then translate this knowledge into recommendations for clinical practice at the level of individual healthcare providers, healthcare systems design, stroke guidelines, and healthcare policies.

Methods

Using Interpretive Description, a qualitative research methodology, we conducted semi-structured interviews with 16 stroke survivors aged 18-55 living in British Columbia, Canada to explore their experiences during stroke recovery, and to determine what supports and resources are needed. The interview transcripts were analyzed using broad-based coding and thematic analysis to identify key themes in the interview material.

Results

Key themes include (1) delayed diagnosis of young stroke; (2) inability of current assessment tools to capture nuanced cognitive deficits; (3) lack of psychological/psychiatric support throughout stroke recovery; (4) challenges in finding relevant and accessible community resources; and (5) lack of follow-up resources for chronic management of stroke deficits.

Conclusions

Young stroke survivors experience unique challenges in British Columbia. With this information, we have made recommendations for clinical practice and healthcare systems in BC to improve care of young stroke survivors. This knowledge has the potential to inform other healthcare systems across the world.

Background and Aims

Stroke is an important cause of morbidity and mortality in pediatrics and large studies are needed at both academic and non-academic hospitals to better understand the pathogenesis of pediatric stroke. Large administrative datasets can provide information on risk factors in neonatal and pediatric stroke.

Methods

The data for patients aged 0-18 with a diagnosis of either ischemic or hemorrhagic stroke were extracted from the Cerner Health Facts EMR Database from 2000-2018. Patients were subdivided by age. The prevalence of established risk factors for pediatric stroke was assessed amongst the extracted cases.

Results

10,621 children were identified with stroke. 6,271(59%) were ischemic and 4,350(41%) were hemorrhagic. The percentage of combined stroke by age were 33%(<1 year), 20%(1-4 years), 14%(5-9 years), 11%(10-13 years), and 22%(14-18 years). The most frequently identified risk factors for ischemic stroke were hypertension(36%), trauma(27%), hyperlipidemia(26%) and malignancy(19%). Moyamoya(3%), congenital heart disease(5%), and dissection(1%) were rare in this dataset. The most common risk factors seen with hemorrhagic stroke were trauma(55%), malignancy(11%), arrhythmia(10%) and hypertension(9%).

Conclusions

This is the largest retrospective study of pediatric stroke of its kind from hospitals across the US in both academic and non-academic clinical settings. Many traditional adult risk factors for stroke are prevalent in pediatric patients with ischemic and hemorrhagic stroke, while common comorbidities in pediatric stroke diagnosed in academic centers, such as Moyamoya, congenital heart disease, and coagulation defects are less frequently diagnosed. A prior diagnosis of trauma and malignancy are prevalent in pediatric patients with both ischemic and hemorrhagic stroke.

Background and Aims

This study aimed to cluster multifaceted functional recovery patterns of first-ever stroke patients using the unsupervised learning algorithm of artificial intelligence (AI).

Methods

This study was an interim analysis of the Korean Stroke Cohort for Functioning and Rehabilitation (KOSCO) dataset, which is a prospective multicenter cohort. Multifaceted functional assessments were performed five or six times repeatedly from seven days to 24 months of stroke onset. Out of 7,858 patients enrolled, 4,389 ischemic stroke (IS) and 1,146 hemorrhagic stroke (HS) patients who completed the functional assessment at 24 months after onset were included in this analysis. In k-means clustering analysis, multifaceted functional assessment scores, demographic features, and clinical information were used as input variables. The optimal cluster k number was determined by finding the highest k with at least a silhouette score of 0.2. All statistical analysis was implemented using R (version 4.0.3).

Results

IS patients were clustered into 11 groups while HS patients were clustered into 13 groups. In both IS and HS, each cluster showed distinct clinical characteristics and functional recovery pattern which included the overall high function group, the overall low function group, the gradual improvement group, the late declining group, etc. Each cluster were clearly distinguished by age, initial stroke severity, and lesion location, etc.

Conclusions

Early identification and accurate prediction of long-term functional outcome will be useful for developing customized treatment for these patients.

Acknowledgment

Supported by a grant from the Korea Centers for Disease Control and Prevention (2019E-320202) and the NRF grant, provided by the Korean government (NRF-2020R1A2C3010304).