Where the hell are the protocols? High income countries need this also since insurance kicks you off before you have adequately recovered
Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries—A Systematic Review
Echezona Nelson Dominic Ekechukwu1,2†, 
Paul Olowoyo3,4†, 
Kingsley Obumneme Nwankwo5,6, 
Olubukola A Olaleye7, 
Veronica Ebere Ogbodo8, 
Talhatu Kolapo Hamzat7 and 
Mayowa Ojo Owolabi9,10,11*- 1Department of Medical Rehabilitation, Faculty of Health Sciences and Technology, College of Medicine, University of Nigeria, Enugu, Nigeria
- 2LANCET Physiotherapy and Wellness and Research Centre, Enugu, Nigeria
- 3Department of Medicine, Federal Teaching Hospital, Ido Ekiti, Nigeria
- 4College of Medicine and Health Sciences, Afe Babalola University, Ado Ekiti, Nigeria
- 5Stroke Control Innovations Initiative of Nigeria, Abuja, Nigeria
- 6Fitness Global Consult Physiotherapy Clinic, Abuja, Nigeria
- 7Department of Physiotherapy, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
- 8Department of Physiotherapy, University College Hospital, Ibadan, Nigeria
- 9Department of Medicine, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
- 10University College Hospital, Ibadan, Nigeria
- 11Blossom Specialist Medical Centre, Ibadan, Nigeria
Background: Given the limited
healthcare resources in low and middle income countries (LMICs),
effective rehabilitation strategies that can be realistically adopted in
such settings are required.
Objective: A systematic review of
literature was conducted to identify pragmatic solutions and outcomes
capable of enhancing stroke recovery and quality of life of stroke
survivors for low- and middle- income countries.
Methods: PubMed, HINARI, and Directory
of Open Access Journals databases were searched for published Randomized
Controlled Trials (RCTs) till November 2018. Only completed trials
published in English with non-pharmacological interventions on adult
stroke survivors were included in the review while published protocols,
pilot studies and feasibility analysis of trials were excluded. Obtained
data were synthesized thematically and descriptively analyzed.
Results: One thousand nine hundred and
ninety six studies were identified while 347 (65.22% high quality) RCTs
were found to be eligible for the review. The most commonly assessed
variables (and outcome measure utility) were activities of daily living
[75.79% of the studies, with Barthel Index (37.02%)], motor function
[66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min
walk test (38.67%)]. Majority of the innovatively high technology
interventions such as robot therapy (95.24%), virtual reality (94.44%),
transcranial direct current stimulation (78.95%), transcranial magnetic
stimulation (88.0%) and functional electrical stimulation (85.00%) were
conducted in high income countries. Several traditional and low-cost
interventions such as constraint-induced movement therapy (CIMT),
resistant and aerobic exercises (R&AE), task oriented therapy (TOT),
body weight supported treadmill training (BWSTT) were reported to
significantly contribute to the recovery of motor function, activity,
participation, and improvement of quality of life after stroke.
Conclusion: Several pragmatic, in terms
of affordability, accessibility and utility, stroke rehabilitation
solutions, and outcome measures that can be used in resource-limited
settings were found to be effective (AND WHERE THE FUCK ARE THEY?)in facilitating and enhancing
post-stroke recovery and quality of life.
Introduction
Stroke is a major public health challenge in many Low- and Middle- Income Countries (LMICs) (1, 2). It is a leading cause of disability and premature mortality (3). Stroke is a common cause of severe financial hardship and poverty (4) and resources for stroke care and rehabilitation are sparse in LMICs (5). Rehabilitation services are typically limited and not easily affordable (6, 7).
Although, there are several proven therapies and rehabilitation
strategies for stroke in high income countries, these are not directly
transferrable to LMICs (8).
Many LMICs have minimal health care spending and any model of stroke
rehabilitation for this region must not only be effective but practical
and sustainable in terms of affordability, availability, accessibility
and acceptability (7, 8).
The global burden associated with stroke underscores the need for
strategies to circumvent current trends and check the projected increase
in stroke incidence in LMICs (1).
We conducted a systematic review of RCTs of
interventions that addressed recovery of functioning, and enhancement of
quality of life after stroke and discussed effective, cost-saving and
practical rehabilitation models to improve clinical outcomes and quality
of life among stroke survivors in LMICs.
The two main objectives of the review are therefore:
1.
To determine effective interventions/modes of care delivery that
enhances post-stroke recovery and quality of life and the outcome
measures utilized.
2.
To identify effective stroke rehabilitation interventions that would
constitute pragmatic (cost-effective, accessible, and utilizable)
solutions in lower and middle income countries.
Methods
This systematic review of literature was based on the
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) guideline. Ethical standards necessary for the conduct of a
systematic review were maintained. The study was registered with
PROSPERO (CRD42020138454).
Search Strategy
We conducted a search of PubMed, HINARI, and Directory of
Open Access Journals (DOAJ) databases for articles published up to
November 2018 using the Patient-Intervention-Comparison-Outcome (PICO)
format with stroke (Patient Problem), non-pharmacologic stroke
rehabilitation/neurorehabilitation strategies (Intervention), stroke
recovery (Outcome) and quality of life (Outcome) as some of the
keywords. We however did not specify comparison groups in the search
strategy.
Eligibility Criteria
Only studies that were identified as completed randomized
controlled trials (RCTs), that involved adult stroke survivors (age ≥
18 years) who underwent non-pharmacological rehabilitation in both the
intervention and comparison groups, and with available full text were
included in this review. However, published protocols, pilot and
feasibility studies, and non-English language articles were excluded.
Data Extraction
The titles and abstracts of articles were screened by the
authors and studies that did not meet the eligibility criteria were
excluded. Full texts of eligible studies were further scrutinized and
the following information were obtained and recorded in prepared data
extraction form: citation, number of study participants, purpose of the
study (specific construct targeted), type of intervention, type of
control, and outcome of intervention (between intervention and control
groups difference) (see Supplementary Table).
Quality Appraisal
The quality of the articles was assessed using JADAD scale (9).
The scale also known as the Oxford quality scoring system has 7 items
with a maximum score of 5 and a minimum score of 0. For the purpose of
this review, studies with JADAD scores <3 were rated as low quality
while those with scores ≥3 were rated as high quality studies.
Data Synthesis
Thematic presentation of findings of the reviewed studies
was done in line with the objectives of the review. Stroke recovery and
their outcomes were operationalized using the broad categories of
functioning based on the International Classification of Functioning,
Disability and Health (ICF) conceptual framework (10).
Thus, stroke rehabilitation interventions and outcomes assessed in the
various studies were presented according to their effects on the
recovery of body functions, activity and participation. The efficacy of
trial interventions on quality of life was also presented as a separate
theme. Stroke care models identified as effective in the reviewed
articles were also presented as a specific theme. Summaries of the
quality of studies that addressed each of the themes were presented.
Results
A total of 1996 studies were obtained from the electronic
searches of the databases, while the findings of 347 studies with
available full text articles were synthesized and presented. One
thousand, six hundred and thirty-five articles were excluded because
they did not meet with the inclusion criteria while 15 articles that
contained duplicate data were also excluded. Details are presented in
the PRISMA flowchart (Figure 1).
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