Cost-Effectiveness of Telerehabilitation Compared to Traditional In-Person Rehabilitation: A Systematic Review and Meta-Analysis

 Survivors don't give a flying fuck about cost; what are the recovery results? Are you THAT BLITHERINGLY STUPID?

Cost-Effectiveness of Telerehabilitation Compared to Traditional In-Person Rehabilitation: A Systematic Review and Meta-Analysis 

Aviraj K. Shambushankar • Jobinse Jose • Sridevi Gnasekaran • Gurveen Kaur

Published: February 14, 2025

DOI: 10.7759/cureus.79028

Cite this article as: Shambushankar A K, Jose, Gnasekaran S, et al. (February 14, 2025) Cost-Effectiveness of Telerehabilitation Compared to Traditional In-Person Rehabilitation: A Systematic Review and Meta-Analysis. Cureus 17(2): e79028. doi:10.7759/cureus.79028

Abstract

This systematic review and meta-analysis evaluated the cost-effectiveness of telerehabilitation compared to traditional in-person rehabilitation. A comprehensive search of PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Ovid databases identified 14 eligible studies. The analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, assessing economic outcomes using incremental cost-effectiveness ratios (ICERs) and quality-adjusted life years (QALYs).

Findings indicate that telerehabilitation was cost-effective in three out of 14 studies included in the cost-effectiveness analysis. The mean ICER for telerehabilitation compared to traditional rehabilitation varied, with a probability of cost-effectiveness reaching 90% at a willingness-to-pay (WTP) threshold of $30,000 per QALY. However, at a WTP threshold of $0, the probability of cost-effectiveness remained low, suggesting that telerehabilitation does not always dominate in cost-effectiveness analyses.

The study highlights the potential of telerehabilitation to provide similar or improved health outcomes compared to traditional rehabilitation while reducing travel costs and enhancing patient access. Increased patient satisfaction, reduced hospital readmissions, and improved adherence to rehabilitation protocols contributed to the economic benefits observed. However, methodological heterogeneity across studies remains a limitation.

Given the growing adoption of digital health technologies, telerehabilitation presents a viable and economically efficient alternative to in-person rehabilitation. Policymakers should consider integrating telerehabilitation into routine healthcare services, particularly in resource-constrained settings, to optimize cost-effectiveness and enhance accessibility. Further research should focus on standardizing cost-effectiveness evaluation methods to strengthen evidence for large-scale implementation.

Introduction & Background

Telehealth is any use of technology to communicate and exchange information among patients and health practitioners across a distance [1]. Telerehabilitation is a kind of telehealth intervention where rehabilitation services are offered via phone, the Internet, and remote devices [2]. Rehabilitation has been used in different disease conditions such as schizophrenia [3], diabetes mellitus [4], dementia [5], etc., for a long period. Telerehabilitation is found to be effective in diseases like heart failure [6], stroke [7], hip replacement [8], total knee arthroplasty [9], chronic low back pain [10], breast cancer [11], etc. There has been a huge increase in the use of telehealth globally since COVID-19 [12,13]. Telerehabilitation can improve accessibility [14], utilization of healthcare services [15], improving health outcomes, reducing health inequalities [16], and reducing the waiting time and need for travel [17,18]. It has also improved patient and provider satisfaction and augmented clinical effectiveness [19,20]. Numerous systematic reviews have been conducted to assess the impact of telerehabilitation on patient outcomes [21], while others have examined its effectiveness across various types of healthcare providers [22]. Various studies have been done on the effectiveness of telerehabilitation in different disease conditions, like brain injury [23], stroke [24], and cardiovascular diseases [25].

One of the significant challenges associated with integrating technology into healthcare is the rising cost of healthcare services. Healthcare costs are increasing due to progress in medical technology, demographic aging, an increasing number of healthcare services, and provider-induced demand [26]. Therefore, health providers should have the goal of achieving high-quality services while restraining costs. Economic evaluations like cost-effectiveness analysis (CEA), cost-utility analysis (CUA), and cost-benefit analysis (CBA) play a crucial role in healthcare by systematically assessing the costs and outcomes associated with various interventions. These evaluations help healthcare providers and policymakers make informed decisions to determine which interventions provide the best value for money.

To our knowledge, no published literature comprehensively summarizes the cost-effectiveness of telerehabilitation. This study seeks to thoroughly assess, analyze, and synthesize the published information on the cost-effectiveness of telerehabilitation services. Our objective is to provide a comprehensive overview of the economic impact of telerehabilitation, identifying key areas where telerehabilitation has proven to be cost-effective and highlighting gaps where further research is needed. This will help inform healthcare providers, policymakers, and stakeholders about the potential financial benefits of integrating telerehabilitation into their services and guide future research priorities in this evolving field.

More at link.

Post-stroke care is crucial for optimum recovery

NO, NO, NO! Survivors don't give a flying fuck about 'care'! They want recovery and anyone who suggests otherwise needs to be shot. 

Post-stroke care is crucial for optimum recovery

Stroke, sometimes called a brain attack, occurs when there is a blockage of blood supply to part of the brain or when a blood vessel in the brain ruptures.

Stroke survivors have a wide range of long-term healthcare needs.

After the stroke, they often experience a variety of cognitive, psychosocial and physical difficulties.

The most challenging problems post-stroke are usually physical and cognitive impairment, depressive symptoms, and fatigue.

Even survivors of a mild stroke struggle to regain full independence due to persistent symptoms.

A stroke survivor’s ability to carry out activities of daily living is likely to still be impaired even a year after they had their stroke.

As survivors work towards recovery, they may experience times when they feel like they have taken two steps forward, only to end up taking one step back.

StarPicks

One doctor’s road to interventional radiology

This is normal and to be expected as rehabilitation gains often occur more slowly as time goes by.

Survivors with communication disorders like aphasia (which is caused by damage to the part of the brain that controls language expression and comprehension), would face even more challenges on top of their physical difficulties.

Maintaining basic communication would be a challenging task, let alone engaging in social networks and meaningful activities to reintegrate into their communities.

Unmet needs

After a stroke, survivors often experience emotional and behavioural changes.

The reason is simple: Stroke impairs our brain’s control over our behaviour and emotions.

You or your loved one may experience feelings of irritability, forgetfulness, carelessness or confusion.

About a third of survivors report depressive symptoms and one in five report anxiety in the first months or years after the stroke.

Many stroke survivors and their caregivers also feel abandoned and marginalised by community health services.

Inadequate post-stroke care can create unmet needs for survivors and their caregivers, which are often associated with poor quality of life for the survivor.

These unmet needs can include:

> Rehabilitation and recovery

Stroke patients often require long-term rehabilitation to regain lost function and mobility.

Many patients require ongoing physical, occupational and speech therapy, but may not have access to these services or the financial resources to cover the costs.

> Mental health support

Stroke patients may experience depression, anxiety and other mental health issues because of the physical and emotional challenges of recovery.

Access to mental health services can be limited, and there may also be stigma associated with seeking mental health care.

> Caregiver support

Caregivers play a critical role in supporting stroke patients, but may themselves experience significant stress and burnout.

They may also lack the training and resources needed to provide effective care.

> Social support

Stroke can be a life-changing event that can result in significant changes to a survivor’s social support network.

They may need help rebuilding their social connections and may benefit from peer support groups.

> Education and information

Many stroke survivors and their families have reported feeling overwhelmed and under-informed about the condition and its treatment.

Therefore, they may benefit from access to educational materials, support groups and resources to help them navigate the recovery process.

> Access to healthcare

Stroke patients may face barriers to accessing healthcare, particularly if they live in rural or remote areas.

They may also face challenges in accessing specialised care, such as neurology and rehabilitation services.

Beyond a year

It is a common belief that a survivor’s physical recovery will plateau a year after the stroke.

In the early stages of rehabilitation after a stroke, you can often recover quickly.

However, after a few months, your progress may slow or stagnate – therapists call this the plateau phase.

It is a stage most survivors experience.

But contrary to widespread belief, it doesn’t mean that you can no longer recover any further.

In fact, it is possible to get through the plateau phase and recover even more function.

The goal of rehabilitation is to maintain your function and prevent any deterioration, as well as to better adapt to your long-term limitations.

Maximising physical independence may indeed turn out to be a lifelong task.

The best way to overcome this challenge is to make sure things at home are adapted as necessary to help you get back to your daily life safely.

You may seek advice from a healthcare professional, specifically an occupational therapist, to prescribe customised assistive devices and assistive technology for home modification.

Emotional impact

A stroke is sudden and shocking, and can affect every part of your life, including your emotional well-being.

Every stroke experience is unique, but to most survivors, it feels like a loss of life.

Most survivors come to accept their physical disability, but many remain emotionally vulnerable years after their stroke.

The loss of physical independence may result in a loss of sense of identity, as well as guilt over the burden they are now posing to their family members.

Hence, ongoing psychological support from family, friends and/or healthcare professionals may be needed.

Providing flexible psychological support for stroke survivors can be achieved through a variety of approaches, including:

> Individual therapy

Stroke survivors may benefit from individual therapy sessions with a licensed therapist.

These sessions can be tailored to the person’s specific needs.

> Teletherapy

Teletherapy allows stroke survivors to receive psychological support remotely, via video conferencing or phone calls.

This can be particularly helpful for patients who are unable to travel to the counselling centre, or who live in rural or remote areas.

> Group therapy

In addition to providing therapy in a group, group therapy sessions can give stroke survivors the opportunity to connect with others who have had similar experiences.

This can help survivors realise they are not alone, as well as both receive from and give support to their fellow survivors in the process of undergoing the therapy.

> Peer support

Stroke survivors may benefit from peer support groups, which provide a supportive and empathetic environment for survivors to share their experiences and learn from others who have been through similar challenges.

While group therapy is led by a healthcare professional and aims to bring about a change in mindset or behaviour, peer support groups comprise only of fellow survivors and are meant to help their members cope with their situation.

> Caregiver support

Providing psychological support for caregivers can also benefit stroke survivors, as it can help reduce caregiver stress and improve the quality of care they provide.

This support can be provided through individual or group therapy sessions, or through educational programs designed specifically for caregivers.

> Online resources

There are many online resources available for stroke patients and their caregivers, including educational materials, support groups and forums.

These resources can provide flexible support for patients who may have limited access to in-person services.

It’s important to note that psychological support for stroke survivors should be tailored to the individual’s needs and preferences, and should be provided in a flexible and compassionate manner.

AHA Urges Action Against Racial Inequities in Stroke Care

That's rich that the AHA/ASA is urging action on stroke 'care' when they are the reason nothing ever gets solved in stroke! Their complete lack of leadership in solving stroke means  nothing will get better in stroke recovery for decades. 'Care' might get better but survivors don't give a flying fuck about 'care', they want recovery!

AHA Urges Action Against Racial Inequities in Stroke Care

Stroke is a "disease of disparities," with racial and ethnic inequities in incidence, prevalence, treatment, and outcomes, and research is needed to identify structural or "upstream" interventions to address the problem, the American Heart Association (AHA) says in a new scientific statement.

"There are enormous inequities in stroke care, which lead to significant gaps in functional outcomes after stroke for people from historically disenfranchised racial and ethnic groups, including Black, Hispanic, and Indigenous peoples," writing group chair Amytis Towfighi, MD, professor of neurology, University of Southern California, Los Angeles, says in a news release.

"While research has historically focused on describing these inequities, it is critical to develop and test interventions to address them," Towfighi adds.

The scientific statement was published online May 15 in the journal Stroke.

It follows a 2020 AHA presidential advisory that declared structural racism a fundamental driver of poor health and early death from heart disease and stroke.

Towfighi and colleagues reviewed the literature on interventions to address racial and ethnic inequities to identify gaps and areas for future research.

They note that various interventions have shown promise in reducing inequities across the stroke continuum of care.

For example, data suggest that careful attention to stroke preparedness among patients, caregivers, and emergency medical services (EMS) can reduce inequities in getting people suspected of having a stroke to the emergency department quickly, with delivery of prompt treatment. 

However, insufficient research attention has been paid to reducing inequities in rehabilitation, recovery, and social reintegration, the writing group says.

In addition, most studies have addressed patient-level factors, such as medication adherence, health literacy, and health behaviors, but not upstream social factors such as structural racism, housing, income, food security, and access to care, which also affect stroke incidence, care, and outcomes.

"Combating the effects of systemic racism will involve upstream interventions, including policy changes, place-based interventions, and engaging with the health care systems that serve predominantly historically disenfranchised populations and the communities they serve, understanding the barriers, and collaboratively developing solutions to address barriers," the writing group says.

Further research is needed across the stroke continuum of care to tackle racial and ethnic inequities in stroke care and improve outcomes, they say.

"It's critical for historically disenfranchised communities to participate in research so that researchers may collaborate in addressing the communities' needs and concerns," Bernadette Boden-Albala, DrPH, MPH, vice chair of the writing group, says in the news release.

"Opportunities include working with community stakeholder groups and community organizations to advocate for partnerships with hospitals, academic medical centers, local colleges and universities; or joining community advisory boards and volunteering with the American Heart Association," Boden-Albala adds.

Towfighi encourages healthcare professionals to "think outside the 'stroke box.' Sustainable, effective interventions to address inequities will likely require collaboration with patients, their communities, policymakers and other sectors."

This scientific statement was prepared by the volunteer writing group on behalf of the AHA Stroke Council, the Council on Cardiovascular and Stroke Nursing, the Council on Cardiovascular Radiology and Intervention, the Council on Clinical Cardiology, the Council on Hypertension, the Council on the Kidney in Cardiovascular Disease, and the Council on Peripheral Vascular Disease.

This research had no commercial funding.

Stroke. Published online May 15, 2023. Abstract

Endovascular thrombectomy is cost-effective in acute basilar artery occlusion stroke

 I don't think stroke survivors give a flying fuck about cost effectiveness. I think if you talk to them, they want to know your 100% full recovery statistics.

WILL YOU GET WITH THE PROGRAM?

Endovascular thrombectomy is cost-effective in acute basilar artery occlusion stroke

Julian Schwarting^1,2*, Sebastian Rühling¹, Jannis Bodden¹, Stéphanie K. Schwarting³, Claus Zimmer¹, Dirk Mehrens⁴, Jan S. Kirschke¹, Wolfgang G. Kunz⁴, Tobias Boeckh-Behrens^1† and Matthias F. Froelich^5†

• ¹Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
• ²Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
• ³Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
• ⁴Department of Radiology, University Hospital, LMU Munich, Munich, Germany
• ⁵Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany

Objective: Endovascular thrombectomy is a long-established therapy for acute basilar artery occlusion (aBAO). Unlike for anterior circulation stroke, cost-effectiveness of endovascular treatment has not been evaluated and is urgently needed to calculate expected health benefits and financial rewards. The aim of this study was therefore to simulate patient-level costs, analyze the economic potential of endovascular thrombectomy in patients with acute basilar artery occlusion (aBAO), and identify major determinants of cost-effectiveness.

Methods: A Markov model was developed to compare outcome and cost parameters between patients treated by endovascular thrombectomy and patients treated by best medical care, based on four recent prospective clinical trials (ATTENTION, BAOCHE, BASICS, and BEST). Treatment outcomes were derived from the most recent literature. Uncertainty was addressed by deterministic and probabilistic sensitivity analyses. Willingness to pay per QALY thresholds were set at 1x gross domestic product per capita, as recommended by the World Health Organization.

Results: Endovascular treatment of acute aBAO stroke yielded an incremental gain of 1.71 quality-adjusted life-years per procedure with an incremental cost-effectiveness ratio of $7,596 per QALY. This was substantially lower than the Willingness to pay of $63,593 per QALY. Lifetime costs were most sensitive to costs of the endovascular procedure.

Conclusion: Endovascular treatment is cost-effective in patients with aBAO stroke.

Introduction

Stroke remains the leading cause of long-term disability worldwide and the second most common cause of death despite significant advances in therapy (1). A severe subtype of stroke is acute basilar artery occlusion (aBAO) which accounts for approximately 10% of ischemic strokes caused by intracranial large-vessel occlusion (2).

Affected patients suffer in up to 80% from severe disability or die, despite best medical care (3). Although many patients have been treated by endovascular thrombectomy (EVT) even before it became a standard therapy for the anterior circulation, there have been no prospective randomized trials showing the benefit of endovascular thrombectomy in patients with aBAO until recently (2–4).

Four multicenter, prospective, randomized, controlled trials of endovascular thrombectomy for aBAO were published in 2019–2022: ATTENTION (3), BAOCHE (5), BASICS (6), and BEST (7). Despite regional biases and a heterogeneity in outcome, time windows and thrombolysis rates, these trials provide high-level evidence for improvement of functional outcomes and independence in patients treated with EVT (8).

Cost-effectiveness of EVT after large-vessel occlusions in the anterior circulation was extensively investigated and results in long-term cost-savings for healthcare systems and societies, for instance in the United States, where estimated cost savings are approximately $40 billion/year and are predicted to increase substantially within the next decade (9–12).

To our knowledge, there is no evidence of cost-effectiveness of endovascular thrombectomy for acute basilar artery occlusion. As these data are urgently needed to calculate expected health benefits and financial rewards, for instance for further developments of endovascular treatments, we defined and quantified public health and cost consequences of endovascular treatments for aBAO stroke patients and healthcare systems based on the recent literature.

More at link.

Updated guidelines make stroke management easier

You do realize that stroke survivors don't give a flying fuck about 'management', they want to know your 100% recovery results. Guidelines are worthless, we need EXACT PROTOCOLS. WILL YOU GET WITH THE PROGRAM?

Updated guidelines make stroke management easier

The UAE has an advanced medical infrastructure that allows for rapid investigation and treatment for stroke patients.

Asma Ali Zain | Nov 02, 2022

According to healthcare experts, updated stroke guidelines and newer-generation medication have made stroke clinical management more convenient.

The NCD Alliance, World Stroke Organization and American Stroke Association recently published an update to their policy brief, ‘Acting on stroke and non-communicable diseases: preventing and responding to stroke to work towards universal health coverage’. This was conducted as part of their efforts to address the global and individual impact of stroke within the broader Non-Communicable Diseases (NCDs) response.

The newly updated policy brief focuses on the stroke and NCD response in light of the Covid-19 pandemic and provides evidence-based recommendations to healthcare providers, policymakers and civil society across the stroke continuum of care, from prevention to treatment and rehabilitation, as they work towards Universal Health Coverage (UHC) and other Sustainable Development Goal (SDG) targets.

In the UAE, updated guidelines have focused on several areas. Dr. Haider Ali, Consultant Family Medicine at Medcare Medical Centre Town Square, explained: “The new guidelines have updated information about several areas such as what clinical scenarios to consider for rapid blood pressure lowering therapy. The use of neuroimaging markers alongside clinical markers helps determine risks of haematoma (clot) expansion and helps guide management as well as instructions to hospital physicians to the lack of evidence of compression stockings, corticosteroids, and hyperosmolar fluid.”

He said that Tenecteplase, a newer-generation medication administered through a single injection into a blocked blood vessel has proved to be a game changer. “Previously we were reliant on another medication (alteplase) which needed an hour-long infusion following its injection into the affected blood vessel(s). The fantastic news with Tenecteplase is that we found it caused half as many serious complications when compared to the previously relied upon medication,” he explained.

Dr. Ali also said that those who had this newer treatment were far less likely to need further procedures to remove the brain clot that caused the stroke in the first place (thrombectomy).

Dr. Haider Ali, Consultant Family Medicine at Medcare Medical Centre Town Square

Stroke remains the world’s second leading cause of mortality accounting for 6.6 million deaths a year. It is also the third leading cause of disability. Over 100 million people in the world currently live with the impact of stroke, which can include devastating loss of mobility, cognition and communication as well as negative effects on mental health, social inclusion, and income.

With the global lifetime risk of stroke standing at one in four (an increase from one in six just a decade ago), it is shocking that only 38 per cent of governments around the world report having a national strategy to specifically address stroke, and that only three per cent have identified resources to deliver it. Meanwhile, the upward trajectory of stroke continues, driven by an increased incidence in low- and middle-income countries where public stroke care systems are often underdeveloped.

With an estimated global cost of about US$1 trillion per year, stroke represents a significant brake on international and national efforts to develop sustainable economic growth. Government action remains too slow and investment remains too low, especially when every US$1 spent on stroke prevention yields a return on investment of over US$10.

The statistics are not any different in the UAE where between 8,000 and 10,000 people suffer a stroke annually. It is also estimated that around half of all stroke patients are below the age of 45 compared to figures internationally where 80 per cent of those suffering a stroke are aged 65 or over. “In the UAE, strokes are one of the main causes of disability other than road traffic accidents,’ said Dr. Ali.

He also said that the UAE has an advanced medical infrastructure that allows for rapid investigation and treatment to be possible for life-threatening, and potentially life-changing conditions such as stroke.

“We need to continue working on educating the population on the risk factors for stroke and cardiovascular disease to reduce the incidence we have in the UAE.”

Given the existing backdrop on NCD and stroke mortality, it is imperative that health systems reorient from a single disease approach to integrated care packages across multiple NCDs through a holistic person-centred approach. The integration of NCDs into UHC must be at the core of national and global preparedness for future health threats. UHC ensures financial protection from high out-of-pocket payments and aims to leave no one behind, prioritising marginalised communities, according to the new policy update by the World Stroke Organisation.

Editorial: Ischemic stroke management: From symptom onset to successful reperfusion and beyond

Since you're not even talking about 100% recovery. I guess you don't give a flying fuck about what survivors want!  GET THE HELL OUT OF STROKE AND LET  BETTER PERSONS IN!

Measure recovery and results, NOT groin puncture time or reperfusion. I'd fire everyone involved in this.

“What's measured, improves.” So said management legend and author Peter F. Drucker 

 

Editorial: Ischemic stroke management: From symptom onset to successful reperfusion and beyond

Peter B. Sporns^1,2*, Johanna M. Ospel¹ and Marios-Nikos Psychogios¹

• ¹Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
• ²Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Editorial on the Research Topic
Ischemic stroke management: From symptom onset to successful reperfusion and beyond

Introduction

Fast and complete reperfusion of the occluded vessel territory is the key to every revascularization therapy in stroke patients, no matter if treated with alteplase or endovascular thrombectomy (EVT) (1–4). However, there is room for substantial improvement in time efficiency and techniques to achieve reperfusion [(3, 5), Advani]. This introduction of the Research Topic “Ischemic Stroke Management: From Symptom Onset to Successful Reperfusion and Beyond” left room for a wide variety of topics for articles, which is reflected by a large number of high-quality articles published in this Research Topic (59). The predefined areas of interest included—but were not limited to—the one-stop management of ischemic stroke patients in the angio-suite, novel methods of pre-hospital patient triage, new procedural techniques and software solutions for effective patient triage, clinical consequences of improved time metrics and prediction of functional outcomes following hyperacute reperfusion therapies. The aim of the Research Topic was to investigate the impact of logistical and procedural improvements on the success of reperfusion and the clinical outcome of ischemic stroke patients.

Looking at the studies published in this Research Topic and starting with pre-hospital triage optimization Cabal et al. report that their new prehospital triage test (FAST PLUS) yielded significant reductions of onset-to-groin times in patients receiving EVT, meaning that median onset-to-groin times reduced from 213 to 142 min in their cohort from the Czech Republic. Weissenborn et al. analyzed workflow and outcome metrics of stroke patients undergoing EVT in their German tertiary stroke center as a starting point for optimization. In their analysis, they found several factors leading to a delay in treatment (i.e., medical treatment of a hypertensive crisis, epileptic fits, vomiting, or agitation, repeated brain imaging, and transfer from other hospitals). Hence, they concluded that analyses of workflow and treatment results should be carried out regularly to identify the potential for optimization of operational procedures and selection criteria for patients who could benefit from EVT (Weissenborn et al.).

At least as important as prehospital triage and procedural optimization are the technical results of the thrombectomy procedure itself (5, 6). Thus, various articles in this Research Topic investigated technical and procedural developments. In their retrospective study, Guenego et al. described the impact of clot shape on successful middle cerebral artery M1-segment endovascular reperfusion and found that clot shape as determined on T2^* imaging, appears to be a predictor of successful reperfusion after EVT because angulated and bifurcating clots were associated with poorer rates of successful reperfusion. Moreover, Candel et al. found that the size of stent retriever matters in acute M1 occlusions treated with aspiration-assisted mechanical thrombectomy. A longer stent retriever with a larger nominal diameter achieved a higher complete and successful first pass effect and higher successful reperfusion compared to a shorter stent retriever (Candel et al.). Another analysis by Etter et al. found that application of a new coating to the delivery wire of the Trevo retriever, with the new device being called the “Trevo NXT” stent retriever, was an effective and safe tool for EVT that could be more easily deployed and was especially effective when used for combined approaches. When looking at the definition for successful recanalization of the thrombectomy procedure, Yoo et al. reported that in their international multicenter trial, first-pass excellent reperfusion (defined as TICI 2c-3), was the technical revascularization endpoint that best predicted functional independence and concluded that this should be an angiographic endpoint for future trials, further consolidating prior evidence from published studies.

Previous studies have shown that histological thrombus composition impacts procedural and technical outcomes of EVT, that thrombus composition is associated with stroke etiology and that the thrombus composition itself can be predicted from admission imaging (7–11). In this issue, Eto et al. report that atherosclerotic components in retrieved thrombi might provide useful clues for diagnosing stroke pathogenesis. Their investigation of the association between onset-to-imaging time and radiological thrombus characteristics suggested that elapsed time from stroke onset plays a limited role in the interpretation of radiological thrombus characteristics and their effect on treatment results and should therefore not confound imaging-based thrombus analysis, at least in the early time window (Tolhuisen et al.). Regarding the visualization of thrombus content, LaGarange et al. reported that MicroCT can be used as an indicator for red blood cells-rich composition of clots, and a combination of MicroCT and electron microscopy revealed further valuable information with regard to clot composition.

Regarding the ongoing debate of intravenous thrombolysis plus EVT vs. EVT alone, Maier et al. report that in patients included in the German Stroke Registry, bridging IVT improved rates of successful reperfusion and long-term functional outcome in mothership patients with anterior circulation large vessel occlusion, which is in line with the results of the recently published SWIFT DIRECT trial. This was further confirmed by a meta-analysis concluding that bridging thrombolysis provides more benefits than EVT alone in terms of clinical functional outcomes without compromising safety in AIS patients with LVOs (Li et al.).

Furthermore, several studies in this article collection further investigated indication criteria in special populations, which were not represented by randomized trials. For example, Kastrup et al. reported that in dependent patients, EVT led to less patients with poor outcomes and smaller infarcts compared to intravenous thrombolysis alone.

Discussion and future challenges

The collection of articles in this Research Topic contributes to the continuous evolvement of further defining patient subgroups that will benefit from hyperacute reperfusion therapies. As an example, there are three currently ongoing randomized controlled trials investigating the benefit of EVT in patients with medium vessel occlusions (DISTAL, NCT05029414, ESCAPE-MeVO, NCT05151172, and DISCOUNT, NCT05030142). Defining imaging and clinical characteristics to identify potential EVT candidates within this patient subgroup will help to treat as many stroke patients as possible with the game-changing endovascular thrombectomy but, on the other hand, also help to prevent harming patients, who are very unlikely to benefit. Further logistic and procedural improvements will pave the way toward treating patients even more effectively and in the end find the optimal and fastest therapy for individual stroke patients.

Author contributions

All authors drafted and revised this editorial. All authors contributed to the article and approved the submitted version.

Making Stroke Prevention the Mainstay of National Stroke Strategies - World Stroke Organization

 Good to know they don't give a flying fuck about stroke survivors.  They need to be destroyed and run by survivors. We wouldn't run away from solving stroke like these lazy assholes.

Making Stroke Prevention the Mainstay of National Stroke Strategies - World Stroke Organization

According to a recent WSO analysis, the annual global cost of stroke looks set to hit US$1 trillion by 2030. While treatments for stroke have advanced considerably in recent years, scaling up care in low- and middle- income countries, where the burden of disease is growing fastest, is a particular and complex challenge. While working to ensure equitable access to quality stroke care(NOT RESULTS!) remains a priority that the World Stroke Organization is seeking to address, prevention is always better than cure. Not one of the 12 million people who have a stroke this year wanted this to happen to them and equally no government wants to spend resources on a healthcare crisis that can be addressed at source. This is why WSO advocates strongly for low-cost, population level prevention to be a mainstay of national stroke strategies.

We know what causes stroke - 90% of strokes are linked to 10 modifiable risk factors including hypertension, smoking, overweight/obesity, exercise and alcohol – all of which are linked to other non-communicable diseases including heart disease, dementia, diabetes and cancer. We have strong evidence of where the issues are in the system and how these can be addressed.  Cut Stroke in Half, WSO’s flagship policy initiative, provides a clear roadmap for policy makers that combines population-wide strategies that would reduce stroke incidence for those at low and medium risk where 80% of strokes currently occur. 

The key pillars of Cut Stroke in Half include reducing exposure to stroke risk factors, implementing motivational digital and mobile technologies, facilitating access to low dose combination medications in a single poly-pill for specific groups, and stroke prevention training and deployment of community health workers.

 

Gait measures at admission to inpatient rehabilitation after ischemic stroke predicts 3‐mo quality of life and function

Under what scenario do you have proof that survivors give one flying fuck about predictions?  And suggesting that your tyranny of low expectations is not a valid answer.

Gait measures at admission to inpatient rehabilitation after ischemic stroke predicts 3‐mo quality of life and function

Chen Lin MD

Jungwha Lee PhD

Christopher P. Hurt PhD

Ronald M. Lazar PhD

Yurany A. Arevalo MD

Shyam Prabhakaran MD MS

Richard L. Harvey MD

First published: 09 May 2020

https://doi.org/10.1002/pmrj.12402

Abstract

Objective

Ischemic stroke can impact a patient's quality‐of‐life, but the extent is unknown. We evaluated the association between gait measures during inpatient rehabilitation facility with quality‐of‐life scores and function at 3‐mo in patients with stroke.

Methods

6‐min walk test and 10‐m walk test were recorded on admission to rehabilitation. We analyzed the association between gait function at rehabilitation and 3‐mo quality‐of‐life and poor functional outcome (modified Rankin scale >2) using multivariable logistic regression.

Results

85 patients (mean age 68.3 ± 14.9 yr; 54.3% male) were enrolled. In adjusted analyses, an increase of 0.31 m/s (ie, 1 SD) on the 10‐m walk test was linked with a decreased odds of impaired lower extremity quality‐of‐life by 94% (OR 0.06, 95% CI 0.01‐0.52; P = 0.01), and decreased odds of poor functional outcome by 98% (OR 0.02, 95% CI <0.01‐0.47; P = 0.01). For 6‐min walk test, an increase of 109.5 m (ie, 1 SD) was linked with decreased odds of having impaired lower extremity quality‐of‐life by 1% (OR 0.99, 95% CI 0.98‐1.00; P < 0.01) and poor functional outcome by 1% (OR 0.99, 95% CI 0.99‐1.00; P = 0.04).

Conclusions and Relevance

Gait measurements at rehabilitation can predict 3‐mo lower extremity quality‐of‐life and function.
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Interhemispheric Modulation of Dual-Mode, Noninvasive Brain Stimulation on Motor Function

I don't think stroke survivors give a flying fuck about Motor evoked potential crapola. They want to know whether it produced better recovery results. WELL DID IT?

Interhemispheric Modulation of Dual-Mode, Noninvasive Brain Stimulation on Motor Function

 Eunhee Park, MD1, Yun-Hee Kim, MD1, Won Hyuk Chang, MD1, Tae Gun Kwon, MD1, Yong-Il Shin, MD1,2,3
1Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; 2Department of Rehabilitation Medicine, Pusan National University School of Medicine, Yangsan; 3Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
Objective  
To investigate the effects of simultaneous, bihemispheric, dual-mode stimulation using repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) on motor functions and cortical excitability in healthy individuals. 
Methods  Twenty-five healthy, right-handed volunteers (10 men, 15 women; mean age, 25.5 years) were enrolled. All participants received four randomly arranged, dual-mode, simultaneous stimulations under the following conditions: condition 1, high-frequency rTMS over the right primary motor cortex (M1) and sham tDCS over the left M1; condition 2, high-frequency rTMS over the right M1 and anodal tDCS over the left M1; condition 3, high-frequency rTMS over the right M1 and cathodal tDCS over the left M1; and condition 4, sham rTMS and sham tDCS. The cortical excitability of the right M1 and motor functions of the left hand were assessed before and after each simulation. 
Results  Motor evoked potential (MEP) amplitudes after stimulation were significantly higher than before stimulation, under the conditions 1 and 2. The MEP amplitude in condition 2 was higher than both conditions 3 and 4, while the MEP amplitude in condition 1 was higher than condition 4. The results of the Purdue Pegboard test and the box and block test showed significant improvement in conditions 1 and 2 after stimulation. 
Conclusion  Simultaneous stimulation by anodal tDCS over the left M1 with high-frequency rTMS over the right M1 could produce(I would fire people using weasel words like this.) interhemispheric modulation and homeostatic plasticity, which resulted in modulation of cortical excitability and motor functions.
Keywords  Bihemispheric stimulation, Transcranial direct current stimulation (tDCS), Transcranial magnetic stimulation (TMS), Interhemispheric modulation, Motor function

Predictors of physical independence at discharge after stroke rehabilitation in a Dutch population

Who gives a flying fuck about predictions? What the hell are your results in getting survivors to 100% recovery.?
http://insights.ovid.com/crossref?an=00004356-201703000-00005

International Journal of Rehabilitation Research. Internationale Zeitschrift Fur Rehabilitationsforschung. Revue Internationale De Recherches De Readaptation. 40(1):37-45, MAR 2017

Antonia F Ten Brink; Tibor R S Hajos; and 8 more
DOI: 10.1097/MRR.0000000000000198
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Abstract

UNASSIGNEDThe aim of this study was to identify predictors, available at admission, of physical independence at discharge from inpatient rehabilitation. Secondary aims were to identify predictors of functional gain and length of stay (LOS). We included 1310 adult stroke patients who were admitted for inpatient rehabilitation in five Dutch rehabilitation centres. Data on the Utrecht Scale for Evaluation of Clinical Rehabilitation at admission and discharge (physical and cognitive independence, mood, pain and fatigue), age, sex and in a subsample stroke characteristics as well were collected. A prediction model was created using random coefficient analysis. None of the stroke characteristics were independently associated with physical independence or functional gain at discharge, or LOS. Higher physical and cognitive independence scores and severe pain at admission were predictors of higher physical independence scores at discharge. Furthermore, lower physical independence scores, higher cognitive independence scores, less pain at admission and younger age predicted more functional gain. Finally, lower physical and cognitive independence scores at admission and younger age predicted longer LOS. Physical independence at admission was the most robust predictor for rehabilitation outcome in a Dutch rehabilitation setting. To a lesser extent, age, cognitive independence and pain predicted rehabilitation outcome after stroke. Treatment of cognition and pain should be taken into account during rehabilitation. Further work needs to be carried out to establish whether focusing on these factors improves outcome after rehabilitation.

An abnormal "one-leg balance" test predicts cognitive decline during Alzheimer's disease

I'm obviously screwed but ask your doctor what this means for you. I can't do the 5 second test, I'm not elderly and I have no cognitive impairment( you commentors can go take a flying fuck).

An abnormal "one-leg balance" test predicts cognitive decline during Alzheimer's disease

Rolland Y, Abellan van Kan G, Nourhashemi F, Andrieu S, Cantet C, Guyonnet-Gillette S, Vellas B.

Source

Inserm, U558, Toulouse, France. rolland.y@chu-toulouse.fr

Abstract

Among elderly without cognitive impairment, poor physical performances have been reported to predict cognitive decline and dementia. Our aim was to explore the predictive value of balance impairment for cognitive decline in 686 community-dwelling Alzheimer's disease (AD) patients (REAL.FR study). Being unable to stand on one leg for five seconds or more defined balance impairment. Cognitive decline was assessed using the Mini-Mental Status Examination (MMSE) score. Co-morbidities, behavioral and psychological symptoms of dementia (BPSD) using the Neuropsychiatric Inventory score, medication, and level of education were assessed at the hospital. MMSE and balance were reported every six months during two years. Linear mixed model analyses were performed. At baseline, participants with balance impairment (15.2% of the sample) were significantly older, had a lower MMSE score and more BPSD, co-morbidities, and medication. After adjustment for the potential covariates, the presence of balance impairment at each assessment was associated with a mean MMSE decline of 9.2 (1.4) points at two years; having no balance impairment at each assessment was associated with a mean MMSE decline of 3.8 (0.3) points at two years (p < 0.001). An abnormal one-leg balance test is a marker of more advanced dementia and predicts a higher rate of cognitive decline.