Global Burden of Disease and Stroke-Related Disability
Preventive measures and improved health care led to a decrease of age-standardized stroke mortality rates over the last few decades, while the absolute number of people affected per year by a new stroke, stroke-related deaths, and the number of stroke survivors living in our societies considerably increased leading to a growing burden of disease and related disability (1). From 1990 to 2010 mortality rates decreased in high-income countries (−37%, 95% confidence interval [95% CI] −31 to −41%) and in low- and middle-income countries (−20%, 95% CI −15 to −30%). In the same time stroke-related deaths (absolute number), number of new stroke survivors, number of stroke survivors living in the society, and lost disability-adjusted life-years all increased (on average by +26, +68, +84, +12%, respectively). Similarly, the Global Burden of Disease Study 2015 group reported an increase of ischemic stroke prevalence (number of stroke survivors living in societies) by 21.8% from 2005 to 2015 (i.e., from 20 467.3 to 24 929.0 thousands) and of years lived with disability by 22.0% (i.e., from 2 999.9 to 3 659.9 thousands) during that time (2).
With the demographic developments to be foreseen (population on average growing older in many countries or less dying from communicable diseases) these trends will continue and societies around the globe are well-advised to plan their health-care resources and societal efforts to cope with the increase in neuro-disabilities efficiently.
Effectiveness of Stroke Rehabilitation
Both stroke prevention and effective stroke rehabilitation can decrease the burden of stroke-relating disabilities. This review focuses on options offered by stroke rehabilitation and ways to promote its effectiveness through evidence-based guidelines. At a regional or local level such guidelines can be implemented by clinical pathways, i.e., structured, multidisplinary, and multi-step plans of care that then facilitate effective stroke rehabilitation.
Indeed, dedicated care in multidisciplinary stroke units leads to higher rates of independence with activities of daily living (ADL) and results in less need to receive long-term institutional care after stroke (3). In this Cochrane review, a meta-analysis including 21 randomized controlled trials (RCTs) with a total of 39,994 participants showed a reduced rate of death or institutionalized care (OR 0.78, 95% CI 0.68 to 0.89; P = 0.0003) and death or dependence (OR 0.79, 95% CI 0.68 to 0.90; P = 0.0007) after stroke unit care compared to care in general wards post stroke, without significantly increasing length of stay, and independent of age, sex, or stroke severity.
In addition, it could be shown that specific interventions for stroke rehabilitation promote functional recovery and reduce disability: Both arm-robot therapy and mirror therapy have robustly shown to reduce motor deficits and enhance arm function (4, 5). Similarly, the use of electro-mechanical gait training increases the number of stroke patients that re-gain the ability to walk (6) and the use of treadmill training (with partial body-weight-support) helps to improve walking speed and walking endurance among ambulatory stroke survivors (7).
Thus, contingent to the availability of multidisciplinary specialized stroke services, knowledge about effective rehabilitation therapies (evidence), and both the skill and resources to apply them in clinical practice stroke-related disability can effectively be reduced among stroke survivors world-wide.
Evidence-Based Stroke Rehabilitation, Obstacles for Implementation, and Guidance by Practice Recommendations
Necessary health care structures for stroke rehabilitation are, however, not available in many countries. Stroke service teams integrate aside from specialist doctors and nurses various therapeutic professions such as physiotherapy, occupational therapy, speech and language therapy, (neuro)psychology, and social workers to name just a “core set” of professions.
The density of physiotherapist available in high-income countries is more than 900 per 1 million inhabitants while below 25 in Africa; the corresponding figures for occupational therapists are more than 400 per 1 million inhabitants in high-income countries vs. < 15 per 1 million inhabitants in Africa; and there are basically no speech and language therapists available in most African countries while high-income countries such as USA or Australia have more than 300 per 1 million (8). Lack of resources is prevailing in many other countries to a varying extent (8).
Another issue for best clinical practice is that of knowledge management. The number of published clinical research (clinical trials) directly applicable to clinical practice is rapidly expanding making it more and more difficult, if not impossible for the individual health care professional to keep up-to-date with the existing evidence.
Figure 1 illustrates a steep rise in the number of clinical trial reports on “stroke rehabilitation” listed by PubMed from 1991 to 2017. How should a health care professional be able to search, obtain, critically appraise and synthesize all the evidence that’s becoming available each year?
Figure 1. Stroke rehabilitation—clinical trial publications. The figure shows the number of clinical trials reports per year as listed by PubMed (retrieved from PubMed from https://www.ncbi.nlm.nih.gov/pubmed on 20.11.2018). Note the considerable increase in evidence that became available over the last three decades.
Systematic reviews like Cochrane reviews help to provide a balanced, valid, and mostly up-to-date picture of the available external evidence. They are, however, restricted to only a limited number of health care questions addressed. Thus, while they give a valuable orientation for some topics they are not available for many others. Furthermore, they provide a picture of the evidence, but do refrain from making explicit clinical practice recommendations leaving the reader with a degree of uncertainty how to apply the knowledge.
Evidence-based clinical practice guidelines are meant to provide this guidance. If they are comprehensive, covering a broad range of topics in stroke rehabilitation and are evidence-based they are both valid and clinically useful.[…]