International Stroke Recovery and Rehabilitation Roundtable Consensus Statements Are Driving Growth and Progress in Our Field

REALLY?  I see nothing closer to 100% recovery! You need your mouths washed out with soap for lying! I'd have you all fired for incompetence in getting to 100% recovery!

International Stroke Recovery and Rehabilitation Roundtable Consensus Statements Are Driving Growth and Progress in Our Field

Kathryn S. Hayward, PhD kate.hayward@unimelb.edu.au, Gert Kwakkel, PhD, and Julie Bernhardt, PhDView all authors and affiliations

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https://doi.org/10.1177/15459683231223648

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Stroke recovery and rehabilitation research has grown exponentially over recent decades.¹ Yet, several barriers continued to hamper rapid progress and clinical impact. The International Stroke Recovery and Rehabilitation Roundtables (SRRR) commenced their work in 2015 with the goal to provide consensus recommendations, which if implemented, could impact the trajectory of stroke recovery and rehabilitation research and clinical outcomes. Three roundtables (outputs published in 2017, 2019, and 2023) have delivered 13 consensus statements that provide recommendations related to specific taskforce topics based on research and clinical need (see Table 1). The roundtable agenda is now encompassed within the operations of the International Stroke Recovery and Rehabilitation Alliance.² The third roundtable effort (SRRR3) is the focus of this edition of Neurorehabilitation and Neural Repair. This editorial aims to bring together all roundtable efforts to highlight where they are having impact and future goals to enhance their impact in the field, as well as highlight key SRRR3 taskforce outputs.

Table 1. Topics for Which Consensus Recommendations Were Established in the First, Second, and Third Stroke Recovery and Rehabilitation Roundtable efforts.

Taskforce topic	Provides consensus recommendations for
SRRR1
Timeline definitions3	Common language and definitions for stroke recovery and rehabilitation field and an agreed vision for accelerating progress in stroke recovery research.
Biomarkers4	Biomarkers that were considered ready to be included in clinical trials, and others that were promising and represent a developmental priority.
Standardized measurement of sensorimotor recovery5	Core measurement standards and patient characteristics that should be collected in all future stroke recovery trials to help build our understanding of the trajectory of stroke recovery and aid discovery of new and more targeted treatments.
Preclinical and clinical alignment6	Appropriate preclinical stroke recovery research and to align preclinical to clinical stroke recovery studies to avoid past mistakes and maximize clinical translation.
Monitoring and reporting of stroke recovery research7	Issues identified as limiting stroke rehabilitation research in the areas of developing, monitoring, and reporting stroke rehabilitation interventions
SRRR2
Preclinical and clinical trial development8	Key knowledge units to develop stroke recovery treatment trials that can be addressed within a framework that defines GO and NO-GO decision pathways to guide selection of the most appropriate trial (including phase) given current knowledge.
Cognition9	Cognitive assessments to be integrated into stroke recovery studies generally and defined priorities for ongoing and future research for stroke recovery and rehabilitation.
Translation into practice10	Research evidence to be prioritized for implementation into stroke rehabilitation practice to have maximal impact.
Standardized measurement of quality of movement11	Kinematic and kinetic movement quantification for standardized measurements of sensorimotor recovery in stroke trials.
SRRR3
Control comparator trial design12	Challenges that impact control comparator design that can be addressed with a tool produced to guide control comparator selection, description, and reporting of preclinical and clinical trials in stroke recovery and rehabilitation.
Fatigue13	Definition, clinical screening tools, and outcome measurement for fatigue after stroke and provided a roadmap for future research.
Non-invasive brain stimulation14	Outstanding barriers for the translation of preclinical and clinical research using the non-invasive brain stimulation techniques, transcranial magnetic stimulation, and transcranial direct current stimulation and provided a roadmap for the integration of these techniques into clinical practice.
Standardized measurement of balance and mobility15	Standardized outcome instruments for measuring balance and mobility recovery after stroke to optimize the quality of stroke rehabilitation and recovery studies and to enable data synthesis across trials.

Across all roundtable recommendations, a common theme has been harmonization of terminology, definitions, and outcomes. Addressing the core of our work, we argued that “rehabilitation” as a blanket term for all therapy-based interventions post stroke was problematic, vague, and an impediment to progress.³ Rehabilitation reflects a process of care, while recovery reflects the extent to which body structure and functions, as well as activities, have returned to their pre-stroke state.³ The term “recovery” can be represented as both change (mostly improvement) on a given outcome achieved between 2 (or more) timepoints, and mechanism(s) underlying any observed change (improvement or decline).³ We have established a timeline and associated terminology of stroke recovery phases³ that harmonized what was meant by “acute,” “sub-acute,” and “chronic”. This work placed emphasis on the integration of knowledge about the biology of recovery³ when discussing time course. We have established consensus definitions for a stroke recovery biomarker,⁴ post stroke fatigue,¹³ and active and inactive ingredients of stroke recovery interventions.¹² Concerning outcomes, consensus recommendations are available for stroke details, patient characteristics, and sensorimotor outcomes^5,11,15; cognition⁹; fatigue¹³; and control group types.¹² Since the beginning, an important cross-cutting theme of SRRR consensus statements has been preclinical-clinical alignment, with many roundtables integrating their knowledge and skills to deliver recommendations that are relevant across the translational continuum. Together, this work is elevating the standard of stroke recovery research, increasing the collaborative nature of our work, and pushing our field closer to impactful clinical outcomes.

The implementation of harmonized terminology, definitions, and outcomes is beginning to be observed across evidence sources and demonstrates the impact of SRRR within our field and beyond. Within our field, collaborative groups such as ENIGMA Stroke Recovery and the European Stroke Organization (ESO) motor rehabilitation after stroke consensus-based definition and guiding framework¹⁶ are adhering to sensorimotor outcomes,¹⁷ and along with systematic reviews, for example, Hayward et al¹⁸ and Stinear et al¹⁹, are integrating harmonized terminology of stroke recovery phases. We have seen non-government stroke organization funding calls encourage people to adhere to SRRR consensus statements and use these statements to inform gap analyses.²⁰ However, we still need adherence to the consensus recommendations to continue to grow, especially across federal agencies responsible for funding large scale national and international programs of stroke research. Outside our field, consensus recommendations are becoming increasingly common, with recommendations now available for other neurological conditions including Multiple Sclerosis.²¹

Turning our attention to the latest round of consensus statements, SRRR3 addressed control comparator trial design,¹² fatigue,¹³ non-invasive brain stimulation techniques,¹⁴ and standardized measurement of balance and mobility.¹⁵ Consistent with prior roundtable efforts, SRRR3 applied innovative methods that integrate discussion, ranking, and prioritization to deliver consensus recommendations. Along with producing consensus statements for the field, SRRR3 efforts, like prior roundtables, were global—including over 50 experts from more than 20 countries. All groups had an early career member/s who supported the activities of the group, and were exposed to the consensus work of SRRR and an internationally collaborative group. Highlights from SRRR3 taskforces are summarized. Firstly, the control comparator trial design taskforce developed a decision support tool (CONtrol DeSIGN [CONSIGN], freely available https://www.redcap.link/SRRR-CONSIGN) to address common control design challenges faced by trialists. This taskforce also defined each type of control and when it is useful. The fatigue taskforce produced a roadmap for future research and tackled 4 priority areas: (1) best measurement tools for research, (2) clinical identification of fatigue and potentially modifiable causes, (3) promising interventions and recommendations for future trials, and (4) possible biological mechanisms of fatigue. In a second paper from this taskforce, they expanded on biological mechanisms which has been published alongside the taskforce papers in this edition.²² The brain stimulation taskforce identified outstanding translational bench-bedside barriers to provide a roadmap for use of transcranial magnetic stimulation and transcranial Direct Current Stimulation for stroke recovery and rehabilitation. To facilitate the implementation of their recommendations, a new SRRR3 Unified Non-Invasive Brain Stimulation Research Checklist was developed. Finally, the measurement of balance and mobility group established a standardized set of clinical measurement instruments for investigating lower limb motor function, sitting- and standing-balance, and mobility, along with kinetic and kinematic metrics, including their equipment, to monitor recovery of quality of movement during standing and walking post-stroke. Testing protocols were included in the output from this taskforce to ensure clinical tests are implemented consistently.

The international SRRR recommendations highlight novel approaches and research targets to accelerate progress toward new treatments for recovery post stroke. Ultimately, the collection of SRRR consensus recommendations should be seen as an important stride forward to improve the comparability between stroke recovery and rehabilitation studies, enable the creation of “big data” to help us better predict and manage heterogeneity in recovery post stroke, and improve development and testing of augmented treatment models across the different cross-cultural care systems in high-, middle-, and low-income counties. We urge readers to adopt them and work collaboratively to continue to shape the discourse in our field and the approach taken to address important recovery and rehabilitation research and clinical priorities.

 

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