Stroke rehabilitation clinical practice guidelines in Low and Middle Income Countries: a systematic review of quality & unique features

Introduction: Efforts towards reducing stroke burden have been an immense challenge. One important reasons could be the scope and quality of clinical practice guidelines (CPGs) developed for stroke rehabilitation in Low-and-Middle-Income-Countries (LMICs), restricting its translation to clinical practice. This systematic review aimed to assess the availability, scope and quality of CPGs for stroke rehabilitation in LMICs. Methods: Following PRISMA guidelines, CPGs for stroke rehabilitation in LMICs were searched across four major electronic databases (Medline, EMBASE, CINAHL and PEDro). Additional studies were identified from grey literature and a hand search of key bibliographies and search engines. The availability and content of the CPGs were narratively summarized and quality of de novo CPGs was analyzed using ‘Appraisal of Guidelines REsearch and Evaluation’ (AGREE) tools: version II & Recommendations Excellence (REX) version. . Features of contextualizations/adaptations of non-denovo CPGs were narratively summarized. Results: Twelve CPGs from 10 countries were included. CPGs from Pakistan, Sri Lanka, India, and China were developed de novo. CPGs from Kenya, Philippines, South Africa, Cameroon, Mongolia, and Ukraine were contextualized/adapted based on existing guidelines from high-income-countries. Most contextualized CPGs had limited stakeholder involvement, local health systems/patient pathway analyses. All ten countries included recommendations for physiotherapy, seven for communication, swallowing, and five for occupational therapy services post-stroke. Quality assessment using AGREE-REX and AGREE-II for de novo guidelines was poor, especially scoring low in development & applicability. Conclusion: Contextualized CPGs for stroke rehabilitation in LMICs were scarcely available and not meeting required quality. There is a need for development of context-specific, culturally-relevant CPGs for stroke rehabilitation in LMICs to improve implementation/translation into clinical practice

Global Outcome Assessment Life-long after stroke in young adults initiative-the GOAL initiative : study protocol and rationale of a multicentre retrospective individual patient data meta-analysis

Introduction Worldwide, 2 million patients aged 18-50 years suffer a stroke each year, and this number is increasing. Knowledge about global distribution of risk factors and aetiologies, and information about prognosis and optimal secondary prevention in young stroke patients are limited. This limits evidence-based treatment and hampers the provision of appropriate information regarding the causes of stroke, risk factors and prognosis of young stroke patients. Methods and analysis The Global Outcome Assessment Life-long after stroke in young adults (GOAL) initiative aims to perform a global individual patient data meta-analysis with existing data from young stroke cohorts worldwide. All patients aged 18-50 years with ischaemic stroke or intracerebral haemorrhage will be included. Outcomes will be the distribution of stroke aetiology and (vascular) risk factors, functional outcome after stroke, risk of recurrent vascular events and death and finally the use of secondary prevention. Subgroup analyses will be made based on age, gender, aetiology, ethnicity and climate of residence.Peer reviewe

An automated flowchart for the Modified Rankin Scale assessment: a multicenter inter-rater agreement analysis

Background and objective: The Modified Rankin Scale (mRS) is a widely adopted scale for assessing stroke recovery. Despite limitations, the mRS has been adopted as primary outcome in most recent clinical acute stroke trials. Designed to be used by multidisciplinary clinical staff, the congruency of this scale is not consistent, which may lead to mistakes in clinical or research application. We aimed to develop and validate an interactive and automated digital tool for assessing the mRS – the iRankin. Methods: A panel of five board-certified and mRS-trained vascular neurologists developed an automated flowchart based on current mRS literature. Two international, experts were consulted on content and provided feedback on the prototype platform. The platform contained five vignettes, and five real video cases, representing mRS grades 0-5. For validation, we invited neurological staff from six comprehensive stroke centers to complete an online assessment. Participants were randomized into two equal groups usual practice versus iRankin. The participants were randomly allocated in pairs for the congruency analysis. Weighted kappa (kw) and proportions were used to describe agreement. Results: A total of 59 professionals completed the assessment. The weight-Kappa was dramatically improved among Nurses 0.76 (95% CI 0.55-0.97) x 0.30 (0.07-0.67), and among Vascular Neurologists 0.87 (0.72-1) x 0.82 (0.66-0.98). In the accuracy analysis, after the standard mRS values for the vignettes and videos were determined by a panel of experts, and considering each correct answer as equivalent to 1 point on a scale of 0-15, it revealed a higher mean of 10.6 (±2.2) in the iRankin group and 8.2 (±2.3) points in the control group (p=0.02). In an adjusted analysis, the iRankin adoption was independently associated with the score of congruencies between reported and standard scores (Beta-coefficient 2.22, 95% CI 0.64-3.81, p-value= 0.007). Conclusion: The iRankin adoption led to a substantial or near-perfect agreement in all analyzed professional categories. More trials are needed to generalize our findings. Our user-friendly and free platform is available at www.irankinscale.co

Research, education and practice of tele-neurorehabilitation in low and middle-income countries: a scoping review

BACKGROUND:Tele-neurorehabilitation (TNR) allows for remote delivery of rehabilitation services for those with neurological disabilities. Despite growing global interest and uptake, its adoption remains challenging in Low-and-Middle-Income-Countries (LMICs). OBJECTIVE:To explore available literature on the nature of training and education, research and practice of TNR in LMICs. METHODS:Following PRISMA-ScR guidelines and predefined selection criteria, four databases were screened. Quality assessment was performed using the Joanna Briggs Institute tools. Relevant data was extracted to using a data extraction form in Microsoft Excel and were narratively synthesised under Education/training, Research and Clinical Practice of TNR. RESULTS:We identified no formal structured training courses/programs for TNR users/providers. Sessions were mainly delivered as part of a research project. The included studies highlighted the need to engage stakeholders in TNR research and improve digital-literacy among healthcare providers/users. Development and use of clinical decision-making-tools, models of TNR suitable for varied populations and prior area-mapping were a few suggestions for clinical/research practice. CONCLUSION:There is an immense need to develop academic/structured programs for TNR to build capacity among providers/users in LMICs. Practice must adhere to principles of safety, effectiveness, and based on high quality clinical-guidelines suitable to the context to ensure optimal uptake and practice of TNR in LMICs

sj-docx-2-wso-10.1177_17474930241246157 – Supplemental material for An automated flowchart for the Modified Rankin Scale assessment: A multicenter inter-rater agreement analysis

Supplemental material, sj-docx-2-wso-10.1177_17474930241246157 for An automated flowchart for the Modified Rankin Scale assessment: A multicenter inter-rater agreement analysis by Joao Brainer C de Andrade, Terence J Quinn, Leonardo Augusto Carbonera, Vinicius Viana Abreu Montanaro, Alexandre C Robles, Rafael Pádua Gomes, Saulo Ribeiro and Gisele Sampaio Silva in International Journal of Stroke</p

sj-docx-3-wso-10.1177_17474930241246157 – Supplemental material for An automated flowchart for the Modified Rankin Scale assessment: A multicenter inter-rater agreement analysis

Supplemental material, sj-docx-3-wso-10.1177_17474930241246157 for An automated flowchart for the Modified Rankin Scale assessment: A multicenter inter-rater agreement analysis by Joao Brainer C de Andrade, Terence J Quinn, Leonardo Augusto Carbonera, Vinicius Viana Abreu Montanaro, Alexandre C Robles, Rafael Pádua Gomes, Saulo Ribeiro and Gisele Sampaio Silva in International Journal of Stroke</p

sj-docx-1-wso-10.1177_17474930241246157 – Supplemental material for An automated flowchart for the Modified Rankin Scale assessment: A multicenter inter-rater agreement analysis

Supplemental material, sj-docx-1-wso-10.1177_17474930241246157 for An automated flowchart for the Modified Rankin Scale assessment: A multicenter inter-rater agreement analysis by Joao Brainer C de Andrade, Terence J Quinn, Leonardo Augusto Carbonera, Vinicius Viana Abreu Montanaro, Alexandre C Robles, Rafael Pádua Gomes, Saulo Ribeiro and Gisele Sampaio Silva in International Journal of Stroke</p

sj-docx-5-wso-10.1177_17474930241246157 – Supplemental material for An automated flowchart for the Modified Rankin Scale assessment: A multicenter inter-rater agreement analysis

Supplemental material, sj-docx-5-wso-10.1177_17474930241246157 for An automated flowchart for the Modified Rankin Scale assessment: A multicenter inter-rater agreement analysis by Joao Brainer C de Andrade, Terence J Quinn, Leonardo Augusto Carbonera, Vinicius Viana Abreu Montanaro, Alexandre C Robles, Rafael Pádua Gomes, Saulo Ribeiro and Gisele Sampaio Silva in International Journal of Stroke</p

sj-docx-4-wso-10.1177_17474930241246157 – Supplemental material for An automated flowchart for the Modified Rankin Scale assessment: A multicenter inter-rater agreement analysis

Supplemental material, sj-docx-4-wso-10.1177_17474930241246157 for An automated flowchart for the Modified Rankin Scale assessment: A multicenter inter-rater agreement analysis by Joao Brainer C de Andrade, Terence J Quinn, Leonardo Augusto Carbonera, Vinicius Viana Abreu Montanaro, Alexandre C Robles, Rafael Pádua Gomes, Saulo Ribeiro and Gisele Sampaio Silva in International Journal of Stroke</p