An economic evaluation of a primary care-based technology-enabled intervention for stroke secondary prevention and management in rural China: a study protocol

This is pathetic to the nth degree. Economic analysis does ABSOLUTELY NOTHING TO GET SURVIVORS RECOVERED!  Just maybe you want to analyze the recovery of stroke patients in rural China.

An economic evaluation of a primary care-based technology-enabled intervention for stroke secondary prevention and management in rural China: a study protocol

Enying Gong^1†, Bolu Yang^2†, Xingxing Chen^2,3, Yuhan Li², Zixiao Li⁴, Janet Prvu Bettger⁵, Brian Oldenburg^6,7, Dejin Dong⁸, Lei Si^9,10* and Lijing L. Yan^2,3,11*

• ¹School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
• ²Global Health Research Center, Duke Kunshan University, Kunshan, China
• ³School of Public Health, Wuhan University, Wuhan, China
• ⁴Beijing Tiantan Hospital, Capital Medical University, Beijing, China
• ⁵College of Public Health, Temple University, Philadelphia, PA, United States
• ⁶Academic and Research Collaborative in Health, La Trobe University, Melbourne, VIC, Australia
• ⁷NHMRC CRE in Digital Technology to Transform Chronic Disease Outcomes, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
• ⁸Xingtai Center for Disease Control and Prevention, Xingtai, Hebei, China
• ⁹School of Health Sciences, Western Sydney University, Campbelltown, NSW, Australia
• ¹⁰Translational Health Research Institute, Western Sydney University, Penrith, NSW, Australia
• ¹¹Ningbo Eye Hospital, Wenzhou Medical University, Ningbo, China

Introduction: Secondary prevention of stroke is a leading challenge globally and only a few strategies have been tested to be effective in supporting stroke survivors. The system-integrated and technology-enabled model of care (SINEMA) intervention, a primary care-based and technology-enabled model of care, has been proven effective in strengthening the secondary prevention of stroke in rural China. The aim of this protocol is to outline the methods for the cost-effectiveness evaluation of the SINEMA intervention to better understand its potential economic benefits.

Methods: The economic evaluation will be a nested study based on the SINEMA trial; a cluster-randomized controlled trial implemented in 50 villages in rural China. The effectiveness of the intervention will be estimated using quality-adjusted life years for the cost-utility analysis and reduction in systolic blood pressure for the cost-effectiveness analysis. Health resource and service use and program costs will be identified, measured, and valued at the individual level based on medication use, hospital visits, and inpatients' records. The economic evaluation will be conducted from the perspective of the healthcare system.

Conclusion: The economic evaluation will be used to establish the value of the SINEMA intervention in the Chinese rural setting, which has great potential to be adapted and implemented in other resource-limited settings.

Introduction

Stroke is one of the rising public health challenges worldwide. In 2019, there were ~12 million incident cases of stroke, of which 32.8% were in China (1). Although the stroke incidence rate is increasing, the stroke mortality rate has been decreasing over the past few decades, resulting in a huge number of stroke survivors globally (2). As these stroke survivors need continuous health management and risk control, the spending on post-stroke care causes an economic burden (3). The financial burden of stroke in rural areas is extremely severe (4, 5). As in many undeveloped areas, primary care lacks the capacity to provide guideline-based essential care to stroke patients, and community-based management for secondary prevention of stroke is far from adequate (6). Therefore, it is necessary to emphasize the prevention of recurrent strokes in the rural setting.

The system-integrated and technology-enabled model of care (SINEMA) study was designed to empower both stroke survivors and primary healthcare providers for secondary stroke prevention by training and incorporating both provider-facing and patient-facing mHealth technologies. The effectiveness of the SINEMA model has been evaluated and proven through a two-arm cluster-randomized controlled trial conducted in 50 rural villages of Hebei province in northern China (7). During the 1-year intervention, a statistically significant greater reduction in systolic blood pressure (SBP) was observed in the intervention arm compared with the control arm. Improvement in a few secondary outcomes including a 35–55% relative reduction in stroke recurrence, hospitalization, disability, and death has also been reported, which indicates the great potential benefits of the SINEMA intervention on secondary stroke prevention (8).

Despite indicating the effectiveness of the intervention, cost-effectiveness is another important factor to be considered. Previous economic evaluation studies of mHealth-based stroke prevention were reported to be cost effective. For example, the TEXT-ME trial conducted in Australia, a text message-based intervention for patients with cardiovascular diseases, reported that the intervention could gain 1,143 more QALYs and save a direct medical cost of Aus$10.56 million over a lifetime horizon for a hypothetical cohort of 50,000 patients with cardiovascular diseases in Australia (9). However, previous economic evaluations were mainly conducted in developed countries, and the cost-effectiveness of an integrated mobile health intervention on secondary stroke prevention in a resource-constrained setting like rural China remains unclear. Therefore, the economic evaluation of the SINEMA intervention is necessary. This protocol describes the methods for the economic evaluation of the SINEMA program based in a rural Chinese setting.

Aim and objectives

This protocol describes the methods for the economic evaluation of the SINEMA program, which is nested in the SINEMA trial (8). This study aims to provide an economic evaluation of the SINEMA program to identify, measure, and value key resource and outcome impacts from the SINEMA intervention model compared with usual care for stroke secondary prevention in rural China. A within-trial economic evaluation will be conducted to calculate the within-trial incremental cost-effectiveness ratio to determine the value of the SINEMA intervention model.

Materials and methods

Study design

The economic evaluation is a nested study based on the SINEMA trial, a cluster-randomized controlled trial implemented in 50 villages in rural China. A detailed description of the SINEMA program and intervention design can be found in previous publications (7, 10–12). The economic evaluation will involve a within-trial cost-effectiveness analysis and cost-utility analysis with a 12-month time horizon equal to the follow-up period of the trial. We will calculate the incremental cost-effectiveness ratio in terms of the incremental cost per 1 mmHg change in systolic blood pressure, which is the primary outcome of the trial. In addition, we will also conduct a cost-utility analysis to calculate the incremental cost per quality-adjusted life year (QALY). The SINEMA intervention is deemed as cost-effective if the incremental cost per QALY is no greater than the cost-effective threshold. Following previous research (13), we will adopt the conventional approach by considering the benchmark as 1.5 times of gross domestic product per capita.

Participants and study settings

Study participants in the economic evaluation will be the same as those recruited in the SINEMA trial. Participants were eligible if they were adults (older than 18 years), had a history of stroke diagnosed at a county or higher level hospital, were in a clinically stable condition with at least basic communication ability, and were expected to be available for the 12-month follow-up. Individuals who were unable to get out of bed had severe life-threatening diseases or had an expected life span shorter than 6 months were excluded. All participants were recruited in 50 villages from five townships in a rural county in Hebei Province, China. The county is a provincial-level impoverished county lying on the “stroke belt,” with a stroke burden double the national average level (10). Participants were recruited between 23 June 2017 and 21 July 2017 and followed until 27 July 2018.

Intervention and control

The SINEMA intervention involved provider-side components and patient-facing components and was supported by a digital health system. In brief, village doctors, as primary healthcare providers, received training based on the train-the-trainer to train model. They were also equipped with the SINEMA app, they conducted monthly follow-up visits to patients. Additionally, financial incentives were also provided to encourage their ongoing commitment to deliver quality healthcare services. Stroke patients received monthly follow-up visits delivered by village doctors at the village clinics or their own homes if they had difficulty visiting the clinics. During each visit, they were provided with suggestions about medication use and physical activities. Participants who had access to their own or shared cell phones received one voice message, at no cost to them, for delivering health education information regarding medication adherence and physical activities.

For villages allocated to the control arm, village doctors continued their standard practices, which included practicing general clinical care and performing the “Basic Public Health Services” (BPHS). BPHS was announced when a new healthcare reform plan started in China in 2009, aiming at assisting community health organizations in delivering a set package of basic health services across the country (14). Patients in the control villages received the usual care. In the context of rural China, the usual care involved patients seeking care in village clinics, township healthcare centers, or county hospitals, as necessary. People with hypertension and diabetes may also receive quarterly follow-up visits by village doctors as covered by the Basic Public Health Services (10).

Identification, measurement, and valuation of effectiveness

The intervention effectiveness will be measured by comparing the systolic blood pressure reduction and the QALYs between the intervention and control arm over the 12-month follow-up period.

Measurement of systolic blood pressure as the primary outcome

Blood pressure (BP) was measured as the primary outcome in the SINEMA trial at baseline and 1-year later, following the sample measurement protocol and approach among all participants. Blood pressure was measured on the right upper arm with participants seated and after 5 min of rest, with an electronic BP monitor (Omron HEM-7052). Two measurements were taken, and the mean value was calculated. If the difference between the two systolic BP measures was larger than 10 mmHg, a third measurement was conducted, and the mean value of the last two readings was calculated.

Health state utility

Health state utility (HSU) estimations will be derived from self-reported health-related quality of life (HRQoL) which was measured using the Chinese version of the EQ-5D-5L, a broadly used generic multi-attribute health utility instrument (15) at baseline and 1-year follow-up. For assessing HRQoL, study data collectors who were staff from the Center of Disease Prevention and Control in the nearby county read out the questionnaire and items for participants and collected the data. After answering the questions for EQ-5D, participants were asked to point out the health score by fingers on a paper version of the EQ-Visual Analog Scale, and then, the data collectors entered the responded values into the online survey platform. An HSU was calculated for each respondent by using the Chinese version of population-based preference weights (16), which ranged from −0.391 to 1, with 1 representing the value of full health, 0 representing deaths, and −0.391 representing the worst state.

Stroke recurrence, hospitalization, disability, and all-cause mortality were measured by using questionnaires at one-year follow-up. Medical and deaths records were also extracted from four major hospitals in the region. These data provide information about the status and trajectory of stroke during the trial period.

Identification, measurement, and valuation of resource use and costs

The aim of the economic evaluation is to inform decision-makers about the costs and cost-effectiveness of introducing the SINEMA intervention to stroke patients in rural regions. As such, the economic evaluation will mainly be performed from the health sector perspective, reflecting the cost and values of the healthcare system.

The resources used to support the SINEMA program include as follows: (1) the cost used to support SINEMA program delivery and (2) the health resources used to support the healthcare service delivery to stroke patients. Table 1 describes the detailed measurement and valuation of costs. The research costs, including the investigator's time and data collection, were not included in the analysis. The costs of designing the SINEMA intervention and the digital health system and other “one-off” costs were excluded, but the operation and maintenance costs of the digital health system were included in the analysis.

TABLE 1

Advances in Stroke: Treatments-Acute

If these are advances they are absolutely pathetic. Nothing even remotely close to solving the BHAG(Big Hairy Audacious Goal  of 100% recovery for all.

Advances in Stroke: Treatments-Acute

Joseph P. Broderick and

Michael J. Hill

Originally published18 Feb 2022https://doi.org/10.1161/STROKEAHA.122.036976Stroke. 2022;0:STROKEAHA.122.036976

 

 

Where are we in the stroke world about hyperacute therapies like Draculin, edaravone from Japan, enzognel from New Zealand? What should doctors be giving patients in the first days? fish oil?, statins?, anti-depressants? nitric oxide? ibuprofen? ceria nanoparticles? leg compressions? music? MMP-9? minocycline? levodopa? Honokiol? amantadine? melatonin?

If your doctor doesn't know about all of these they are pathetic. I have written about all of these so your doctor and hospital are incompetent for not knowing about and implementing them. Why the hell are you paying them one red cent?

The World Stroke Academy (WSA) is the eLearning Portal of the World Stroke Organization (WSO).

I have no clue if this is any good at all, I'm not even going to try to figure out how it works. I didn't get far enough in the membership application to find out how much it costs. By looking at this page you can see they have 368 pieces of material. Pathetic, I have over 14,400 blog posts, the vast majority pointing to research.  This is why I call them fucking failures of stroke associations, not even enough information to put in a magazine, and they probably have hundreds of employees.
https://world-stroke-academy.org/wso/#!*menu=3*browseby=6*sortby=1

Royal Surrey County Hospital will continue to provide stroke care following public feedback

Totally fucking pathetic. 'Care' NOT results. I care about you means nothing vs. I can provide these results via these protocols. Which would you rather have? Care or Results? YOU have to change the discussion to results.
http://www.getsurrey.co.uk/news/surrey-news/royal-surrey-county-hospital-continue-13614944
Royal Surrey County Hospital will continue to provide vital stroke care services after patients and their families heavily opposed plans to remove them.
The service will be jointly provided by staff and units from Frimley Park Hospital and Royal Surrey, where an acute stroke unit (ASU) will be located.
Current hyper-acute stroke care provided at Royal Surrey, which treats stroke patients within the first 72 hours of them being admitted, will be taken on by Frimley Park Hospital.
Specialist stroke rehabilitation beds will continue to be provided at Royal Surrey.

This differs from initial proposals which said Royal Surrey would no longer provide specialist stroke care.

Governor pleased with changes made

In a letter sent to the Surrey Advertiser , hospital governor Ray Rogers said: "I and fellow Royal Surrey governors pressed for the Royal Surrey to have an ASU and involvement in rehabilitation rather than everything happening in St Peters and Frimley Park.
"This was clearly the wish of the meeting which the Royal Surrey organised for its Trust members.
"The Royal Surrey after the members’ meeting submitted a proposal on those lines.

"I am pleased to say that the CCGs [clinical commissioning groups] have decided that there should be a 'networked HASU and ASU' arrangement between Frimley and the Royal Surrey with an ASU being located in the Royal Surrey.

"They have also decided that there be bedded specialist rehabilitation in the Royal Surrey linked to the ASU and with access to non-specialist rehabilitation."

The public meeting, held on September 7 at The H G Wells Conference and Events Centre in Woking, discussed the outcome of a 12-week public consultation .
Guildford and Waverley Clinical Commissioning Group (CCG) and NHS North West Surrey undertook a consultation on stroke services in West Surrey which ended in April.

Concerns raised by Waverley patient groups

It was previously recommended that specialist stroke services be consolidated at two sites in west Surrey – at Frimley Park Hospital and St Peter’s Hospital.
Yet these initial proposals were met with concern from Waverley patient groups.
Cranleigh Patients' Participation Group (PPG) asked the public to sign a petition to ensure rapid stroke treatment for residents.
The group said stroke patients would need to travel for over 23 miles to reach Frimley Park Hospital, around twice the travel distance from Cranleigh to Royal Surrey.
A petition was presented to the Guildford and Waverley Clinical Commissioning Group and NHS England in April before the public consultation report was published.
East Surrey NHS body put into special measures as report rates its finances 'inadequate'

'We have responded to the feedback'

A spokesman for NHS Guildford and Waverley Clinical Commissioning Group said: "The CCGs have responded to the feedback received from the public by making amendments to the model of care consulted upon, through close working with providers.
"Both changes to the proposals consulted upon mean that patients will be cared for in the period following hyper-acute stroke care at a site that the public told us was more easily accessible for visitors, who have an important role in supporting their loved ones to recover and rehabilitate."
West Surrey Stroke System Committees in Common (CiC) included members of the Guildford and Waverley CCG and North West Surrey CCG.
Frimley Park Hospital's neonatal unit becomes third in the UK to receive 'prestigious' charitable award
The review of West Surrey services was made following national clinical expert recommendations that hospital care for stroke patients be consolidated into specialist units.
It is part of a two year-consultation of how NHS services could be improved across Surrey.
For more information go to the Guildford and Waverley CCG website here .

Stroke research: almost three times as many patients could be disability-free in future

That as a goal is pathetic, 100% recovery for all is the only goal. Quit being lazy.
http://www.alphagalileo.org/ViewItem.aspx?ItemId=176726&CultureCode=en

24 June 2017 B&K Kommunikation

Virtually no other disease has seen such massive strides in treatment in recent years as stroke.(Really? I don't see much in actual results) Recent studies have confirmed that it is still possible to mechanically remove large vessel occlusions in the brain many hours after a stroke occurs. At the European Academy of Neurology Congress in Amsterdam, experts expressed optimism that the proportion of patients with lives free of serious disability after a major stroke could be increased by 270 per cent.
“The past few years have brought about greater advances in the treatment of stroke than the two previous decades,” said Prof Urs Fischer, Secretary General of the European Stroke Organisation (ESO) and stroke expert at the University of Bern’s Department of Neurology, summarising the latest developments. Advances in stroke therapy were one of the key focuses at the 3rd Congress of the European Academy of Neurology in Amsterdam. “The introduction of endovascular therapy means that we can now treat patients with large vessel occlusions, and the latest research findings show that we will be in a position to save far more stroke patients in future and spare them from serious lifetime disability.”
Stroke is the second most common cause of death worldwide
Stroke is already being talked about as the epidemic of the twenty first century. Around one fifth of all women and one sixth of men worldwide have a stroke at some point in their life. More than one in ten deaths are attributable to stroke, making this cerebrovascular condition the second-largest cause of death in the world. Stroke is also the second most frequent cause of lifetime and serious disability.
Large vessel occlusions also removable
A major milestone came 15 years ago when intravenous thrombolysis was first introduced. Under this procedure, stroke-causing blood clots in vessels of the brain are dissolved using medicine. The drawback of this method is that in around 10 to 20 per cent of cases the occlusions are so large that the treatment does not work sufficiently. A mechanical alternative has been available for a number of years now: endovascular thrombectomy involves removing a clot from a blood vessel in the brain using a catheter inserted via the groin. Prof Fischer: “The clinical effects of these acute stroke treatments are often striking. Patients who are admitted to hospital with serious neurological deficits show signs of improvement immediately after recanalisation. A number of them are even well enough to be discharged after just a few days.” The effectiveness of this method is now well documented: “Eight studies unanimously show that endovascular treatment of patients with acute occlusions of large vessels in the brain is superior to treatment with medication only,” Prof Fischer said.
New data: thrombectomy also helps more than six hours after stroke
Although the number of treatments of this kind is increasing all the time, this pioneering approach currently only benefits a few per cent of patients. One reason is that experts previously believed that mechanical clot removal was only possible within six hours of a stroke. The recently unveiled results of the DAWN study disproved this assumption: 48.6 per cent of patients survived without serious disability when they received a thrombectomy and thrombolysis as a combined treatment for a stroke event that had taken place more than six hours earlier. In the control group with medical management alone, just 13.1 per cent had no complications. “This means a relative reduction in disability of 73 per cent,” Prof Fischer summarised. “These new insights may enable us to increase the number of patients able to lead an independent, disability-free life by up to 270 per cent.”
Major variances in care provision in Europe
“We can only harness the full potential of this option if we adapt structures and processes for stroke care to reflect the latest findings,” explained EAN President-elect Prof Franz Fazekas from Austria’s University Hospital Graz. This is why EAN teamed up with five other medical societies last year to publish guidelines on the use of thrombectomy, which define all of the organisational and personnel requirements from selecting suitable instruments to post-operative care. “A pan-European study conducted by ESO, ESMINT and SAFE together with the EAN showed that provision of care is still unsatisfactory in some parts of Europe when it comes to thrombolysis and thrombectomy,” said Prof Fazekas. “Several European countries are not sufficiently equipped for this latest treatment breakthrough.”
In many cases, patients are denied access to the latest neurological innovations because hospitals do not have stroke units or sufficiently trained staff. “But where a person lives should not dictate whether they receive optimal treatment following such a common and serious event as a stroke,” Prof Fazekas added. “EAN will do everything it can to eliminate these differences as quickly as possible. To achieve this we will work very closely with all of the organisations involved in stroke research and stroke care, just as we did when drawing up the survey and the thrombectomy guidelines.”
Need for improvement also in countries where treatment is good
Even countries with highly developed stroke infrastructure still have room for improvement. This question is discussed in a new report by the European Brain Council, “The Value of Treatment for Brain Disorders”. This publication focuses on unmet needs and treatment gaps in neurology.
In many cases, too much time passes between the stroke event and the start of treatment. “Reducing the symptom-to-needle time is a central aspect of improving patient prognoses,” noted Prof Fazekas. “Sadly, many patients wait far too long before calling the emergency services, despite all the campaigns designed to increase awareness. It is particularly regrettable since the time that elapses before treatment starts can determine whether the patient is left disabled or goes on to live an independent life.”
As the expert confirms, there is still room for improvement within the individual treatment centres. According to the guidelines in place in the majority of European countries, no more than an hour should pass between the arrival of the patient and the start of treatment. Prof Fazekas: “Even 15 years after the effectiveness of intravenous thrombolysis was proven, the door-to-needle time for many patients still exceeds 60 minutes.”
Sources: Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention With Trevo (DAWN), ClinicalTrials.gov Identifier: NCT02142283; Aguiar de Sousa et al. ESO ESMINT EAN SAFE Survey On Acute Endovascular Stroke Care In Europe, Abstract ESOC 2017

What is the logical course of action to solve all the problems in stroke?

The first action is to identify those problems as compared to our stroke associations who don't even acknowledge there are any problems in stroke. Don't you know that prevention press releases and F.A.S.T. are all that is needed? That leaves survivors totally screwed.
My assumption was that just stating the factual needs and problems of stroke survivors would lead to change. Obviously that is totally wrong, entrenched interests in keeping the status quo, stroke associations working only for doctors for example, and researchers going for the easy research, finding a new prediction point for stroke.
The stroke associations believe in not even addressing any of the problems in stroke, they do the lazy press release route and pat themselves on the back for that fucking pathetic nonhelp.

Obviously no one in the stroke medical world really cares about solving problems for survivors. You're screwed, deal with it and be happy you are alive.  

A stroke survivor like me should not be required to solve all my own stroke deficits along with all the incompetency in the stroke medical world. I don't have enough brain cells for that or any minions working for me.

“Aerobic Exercise Prescription in Stroke Rehabilitation: A Web-Based Survey of United States Physical Therapists”

This just shows you how fucking pathetic stroke rehab is. There should be no need to do a survey because all PTs are working from the same stroke protocol. Am I the only person who sees how insanely stupid it is not to have publicly available stroke protocols? And if you hear the comment, 'All strokes are different, all stroke recoveries are different' you have just met an uninformed person. 
https://jnptacceptedarticles.wordpress.com/2017/01/22/just-accepted-aerobic-exercise-prescription-in-stroke-rehabilitation-a-web-based-survey-of-united-states-physical-therapists/
The following article has just been accepted for publication in Journal of Neurologic Physical Therapy:
“Aerobic Exercise Prescription in Stroke Rehabilitation: A Web-Based Survey of United States Physical Therapists”
By
Pierce Boyne, PT, DPT, NCS; Sandra Billinger, PT, PhD, FAHA; Marilyn MacKay-Lyons, MSPT, PhD; Brian Barney, BS; Jane Khoury, PhD; Kari Dunning, PT, PhD
Provisional Abstract:
Background and Purpose. Best practice recommendations indicate that aerobic exercise (AEX) should be incorporated into stroke rehabilitation. However, this may be challenging in clinical settings. Therefore, the purpose of this study was to assess physical therapist (PT) AEX prescription for patients with stroke, including AEX utilization, barriers to AEX prescription, dosing parameters and safety considerations.
Methods. A cross-sectional web-based survey study was conducted. PTs with valid email addresses on file with the state boards of Florida, New Jersey, Ohio, Texas and Wyoming were eligible to participate. After questionnaire development, survey invitations were emailed to all licensed PT in these states. Analysis focused on respondents who were currently involved with clinical stroke rehabilitation in common practice settings.
Results. Results from 568 respondents were analyzed. Most respondents (88%) agreed that AEX should be incorporated into stroke rehabilitation, but 84% perceived at least one barrier. Median prescribed AEX volume varied between practice settings from 20 to 30 minute AEX sessions, 3 to 5 days per week for 2 to 8 weeks. Prescribed intensity was most commonly light or moderate and was determined by the general response to AEX and patient feedback. Only 2% of respondents reported that the majority of their patients with stroke had stress tests.
Discussion and Conclusions. Most United States PTs recognize the importance of AEX for persons post stroke, but clinical implementation can be challenging. Future studies and consensus are needed to clarify best practices and to develop implementation interventions to optimize AEX utilization in stroke rehabilitation.
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Use of Strategies to Improve Door-to-Needle Times With Tissue-Type Plasminogen Activator in Acute Ischemic Stroke in Clinical Practice

This is totally pathetic. The goal should be negative DTN time. With an objective diagnosis in the ambulance with no neurologist needed you should be able to deliver tPA before you get to the hospital. If that is not your goal then get the fuck out of the way and let actual leaders get that done.  No endpoint was measured of total tPA efficacy of reversing the stroke. What a complete fucking waste of otherwise good research. We might have gotten how many minutes do you have to get full recovery after tPA administration. Does no one even know how to run research?
 http://circoutcomes.ahajournals.org/content/10/1/e003227?etoc=

Findings from Target: Stroke

Ying Xian, Haolin Xu, Barbara Lytle, Jason Blevins, Eric D. Peterson, Adrian F. Hernandez, Eric E. Smith, Jeffrey L. Saver, Steven R. Messé, Mary Paulsen, Robert E. Suter, Mathew J. Reeves, Edward C. Jauch, Lee H. Schwamm, Gregg C. Fonarow

https://doi.org/10.1161/CIRCOUTCOMES.116.003227

Circulation: Cardiovascular Quality and Outcomes. 2017;10:e003227

Originally published January 17, 2017

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Abstract

Background—The implementation of Target: Stroke Phase I, the first stage of the American Heart Association’s national quality improvement initiative to accelerate door-to-needle (DTN) times, was associated with an average 15-minute reduction in DTN times. Target: Stroke phase II was launched in April 2014 with a goal of promoting further reduction in treatment times for tissue-type plasminogen activator (tPA) administration.

Methods and Results—We conducted a second survey of Get With The Guidelines-Stroke hospitals regarding strategies used to reduce delays after Target: Stroke and quantify their association with DTN times. A total of 16 901 ischemic stroke patients were treated with intravenous tPA within 4.5 hours of symptom onset from 888 surveyed hospitals between June 2014 and April 2015. The patient-level median DTN time was 56 minutes (interquartile range, 42–75), with 59.3% of patients receiving intravenous tPA within 60 minutes and 30.4% within 45 minutes after hospital arrival. Most hospitals reported routinely using a majority of Target: Stroke key practice strategies, although direct transport of patients to computed tomographic/magenetic resonance imaging scanner, premix of tPA ahead of time, initiation of tPA in brain imaging suite, and prompt data feedback to emergency medical services providers were used less frequently. Overall, we identified 16 strategies associated with significant reductions in DTN times. Combined, a total of 20 minutes (95% confidence intervals 15–25 minutes) could be saved if all strategies were implemented.

Conclusions—Get With The Guidelines-Stroke hospitals have initiated a majority of Target: Stroke–recommended strategies to reduce DTN times in acute ischemic stroke. Nevertheless, certain strategies were infrequently practiced and represent a potential immediate target for further improvements.

Pace of Progress in Stroke Thrombolysis Are Hospitals Running To Stand Still?

This is totally pathetic. The goal should be negative DTN time. With an objective diagnosis in the ambulance with no neurologist needed you should be able to deliver tPA before you get to the hospital. If that is not your goal then get the fuck out of the way and let actual leaders get that done. 
http://circoutcomes.ahajournals.org/content/10/1/e003438?etoc=

Scott J. Mendelson, Shyam Prabhakaran

https://doi.org/10.1161/CIRCOUTCOMES.116.003438

Circulation: Cardiovascular Quality and Outcomes. 2017;10:e003438

Originally published January 17, 2017

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Stroke is a time-sensitive medical emergency and a leading cause of disability in the United States. Therapies to halt and even reverse ischemic injury to the brain, such as intravenous tissue-type plasminogen activator (tPA), are available, but the systems to deliver them rapidly have not been optimized to ensure timely treatment of as many eligible patients as possible. Although ≈40 000 to 50 000 acute ischemic stroke patients per year receive tPA,^1,2 benefits from the drug are not simply related to receiving it or not but rather are closely linked to time from onset to treatment.^3,4 Delays to treatment lead to more disability because every additional 5 minutes is tantamount to the permanent loss of nearly 10 million brain cells.⁵ National guidelines and quality measures have, therefore, emphasized speed of stroke thrombolysis, focusing on the time between patient arrival to the hospital and tPA administration, also known as door-to-needle (DTN) time.^6,7 Alarmingly, recommendations that hospitals evaluate acute ischemic stroke patients and administer tPA within 60 minutes(Wrong goal)of a patient’s arrival to the emergency department have existed since the original National Institutes of Neurological Disorders and Stroke tPA trial.⁸ Despite this, as the first decade of the new millennium closed, US hospitals were not meeting this goal in a majority of patients.

Improving Door-to-Needle Times for Acute Ischemic Stroke

This is totally pathetic. The goal should be negative DTN time. With an objective diagnosis in the ambulance with no neurologist needed you should be able to deliver tPA before you get to the hospital. If that is not your goal then get the fuck out of the way and let actual leaders get that done. 
http://circoutcomes.ahajournals.org/content/10/1/e003242?etoc=

Effect of Rapid Patient Registration, Moving Directly to Computed Tomography, and Giving Alteplase at the Computed Tomography Scanner

Noreen Kamal, Jessalyn K. Holodinsky, Caroline Stephenson, Devika Kashayp, Andrew M. Demchuk, Michael D. Hill, Renee L. Vilneff, Erin Bugbee, Charlotte Zerna, Nancy Newcommon, Eddy Lang, Darren Knox, Eric E. Smith

https://doi.org/10.1161/CIRCOUTCOMES.116.003242

Circulation: Cardiovascular Quality and Outcomes. 2017;10:e003242

Originally published January 17, 2017

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Abstract

Background—The effectiveness of specific systems changes to reduce DTN (door-to-needle) time has not been fully evaluated. We analyzed the impact of 4 specific DTN time reduction strategies implemented prospectively in a staggered fashion.

Methods and Results—The HASTE (Hurry Acute Stroke Treatment and Evaluation) project was implemented in 3 phases at a single academic medical center. In HASTE I (June 6, 2012 to June 5, 2013), baseline performance was analyzed. In HASTE II (June 6, 2013 to January 24, 2015), 3 changes were implemented: (1) a STAT stroke protocol to prenotify the stroke team about incoming stroke patients; (2) administering alteplase at the computed tomography (CT) scanner; and (3) registering the patient as unknown to allow immediate order entry. In HASTE III (January 25, 2015 to June 29, 2015), we implemented a process to bring the patient directly to CT on the emergency medical services stretcher. Log-transformed DTN time was modeled. Data from 350 consecutive alteplase-treated patients were analyzed. Multivariable regression showed the following factors to be significant: giving alteplase in the CT (32% decrease in DTN time, 95% confidence interval [CI] 38%–55%), stretcher to CT (30% decrease in DTN time, 95% CI 16%–42%), patient registered as unknown (12% decrease in DTN time, 95% CI 3%–20%), STAT stroke protocol (11% decrease in DTN time, 95% CI 1%–20%), and stroke severity (National Institutes of Health Stroke Scale score 6–8: 19% decrease in DTN time, 95% CI 6%–31%; National Institutes of Health Stroke Scale score >8: 27% decrease in DTN time, 95% CI 17%–37%).

Conclusions—Taking the patient to CT on the emergency medical services stretcher, registering the patient as unknown, STAT stroke protocol, and administering alteplase in CT are associated with lower DTN time.

4 Ways You Can Reduce Your Risk of Suffering a Stroke

This is totally pathetic for the NSA to consider this their highest aspiration. Fucking press releases.

4 Ways You Can Reduce Your Risk of Suffering a Stroke

We all know our brain is one of the most important organs in our body (it does control bodily functions and memory, after all), yet we rarely ever talk about how serious strokes can be. Maybe it’s because most of us don’t truly understand what these events actually are. Time for a primer.

According to the National Stroke Association, a stroke occurs when blood flow to one area of the brain gets cut off. This stops the flow of oxygen, leading to cell death. Depending on what part of the brain is affected, a person may lose control of certain muscles and may have difficulty remembering things. Because it’s the fifth leading cause of death in the U.S., you should do everything you can to reduce your risk. Make sure to follow these five tips to lower your chances of having a stroke.

1. Increase your fruit and vegetable intake

According to an analysis, eating more fruits and vegetables has been linked to reducing the risk of stroke. The analysis included 20 different studies, which compiled data from over 700,000 people and close to 17,000 strokes. The article mentions that for every 200 grams of fruit eaten a day, the risk of stroke decreased by 32%. For every 200 grams of vegetables, it decreased by 11%. Findings were consistent for both men and women of various ages. In other words, eat up.

2. Avoid high-cholesterol foods

The National Stroke Association mentions having high cholesterol may contribute to stroke. When there’s a lot of fatty substances in the blood, it can lead to plaque buildup in the arteries. We often associate this with heart attack, but it may also lead to a stroke. To lower harmful fat substances in the blood, the American Heart Association says to avoid foods like full-fat dairy products, red meats, and foods high in saturated fat, which contribute to high cholesterol levels in the body. Genetics also play a large role, so be sure to discuss family history of high cholesterol with your doctor.

3. Lower your blood pressure

By lowering high blood pressure, you can reduce risk of stroke and other life-threatening issues like kidney failure and heart attack. According to the National Stroke Association, high blood pressure causes your heart to work harder to pump blood throughout your body. When this happens, major organs like the brain become damaged because of weakened blood vessels. If high blood pressure is not regulated, risk of stroke may increase by four to six times. A few ways to lower blood pressure include following a diet low in fat and sodium and limiting alcohol intake.

Your other best bet is exercise. Mayo Clinic says that regularly working up a sweat can provide health benefits by making the heart stronger. It may take up to three months for exercise to be effective, so it’s important to make it a regular habit. Aim for 150 minutes of moderate-intensity aerobic activity per week, plus some strength training.

4. Say no to cigarettes

The National Institute of Neurological Disorders and Stroke says smoking can double chances of ischemic stroke and increase the risk of hemorrhagic stroke by up to four times. This may be because smoking causes plaque buildup in the artery that delivers blood from the heart to the brain. If that flow gets cut off, you’re in major trouble. Even if you only occasionally smoke, it’s best to give up the habit entirely. And bonus, you’ll save some money.

Collaboration 2.0: Exploring the Future of Research-by-Collaboration in Medical R&D

There are many ways our fucking failures of stroke associations could collaborate with researchers and survivors, this is just one if we had ANY stroke leadership at all. I have to assume our stroke associations have NO intention of doing anything for survivors other than press releases and stroke groups. Fucking pathetic.

Collaboration doesn’t always come easily, but it is a major key to success in the biomedical research and development environment. Despite the explosion of research consortia around the globe, the consortia landscape has gone largely unmapped, resulting in confusion about the efforts and how to participate. Over the last two years, FasterCures’ Consortia-pedia project has been mapping and analyzing the breadth and scope of approaches that a wide range of consortia have adopted to bring together non-traditional partners with a shared R&D goal. In the first FasterCures Webinar of 2016, a panel of experts addressed how to ensure that these collaborations maximize their value to the ecosystem and create thoughtful, productive partnerships.

Moderated by Margaret Anderson of FasterCures, speakers Jane Larkindale of Critical Path Institute, Dalvir Gill of TransCelerate BioPharma and ShaAvhrée Buckman-Garner of the Center for Drug Evaluation and Research (CDER) at the U.S. Food and Drug Administration (FDA) spoke on key themes that lead to success when starting a consortium, ensuring a productive work stream and facilitating outputs to use in the regulatory space.

Starting a New Consortium

To discuss laying a strong foundation for a consortium, Larkindale drew on her experience in leading the Duchenne Regulatory Science Consortium (D-RSC), founded in August 2015. One of the major lessons learned in establishing this collaboration was the importance of gaining buy-in from all stakeholders for the project. Larkindale spoke of the importance to look beyond just the needs of different stakeholder groups and consider what incentives will drive their participation and what timeline will work for their needs.

Not only is listening to the stakeholder community important, but also, Larkindale noted, “Educating the community and understanding what incentives they’re after was very important for getting the buy-in.” She gave the example of groups in the Duchenne space who may have a great deal of experience and knowledge related to the disease and its progression, but have little experience with working with regulatory bodies that endorse the model. Taking the time to educate them about the regulatory process and how it fits into the work the consortium is going to take on was a crucial step.

Larkindale also spoke to the nuts and bolts of getting stakeholder agreement through governance, project management and legal agreements. Since different partners bring different assets to the table, she noted the importance of balancing governance to be equal to each group’s contributions. Finally, all of the needs for each stakeholder group needs to be reflected in the legal agreements. A major issue arose when Larkindale’s team initially developed the agreements for D-RSC with companies in mind. These agreements were unacceptable to state universities, which sent them back to the drawing board.

Critical Factors for a Successful Collaboration

TransCelerate BioPharma is a unique consortium model, representing a single stakeholder group, biopharmaceutical companies. In the last three years, the collaboration has grown to 19 member companies and 14 active initiatives. Gill outlined the five strategic priorities created by the founding member companies, which assess industry challenges and align with all current and future initiatives of the group. Gill said it is important for TransCelerate to remain focused on these priorities because “in order to fulfill the promise of today’s science, we need to be more efficient with what we have.”

Despite having a single stakeholder group represented in TransCelerate’s membership, the consortium interacts with other stakeholders who have the same goal of improving clinical trials. This includes other industry initiatives, investigator sites, the research and contract research organization community and regulatory bodies.

To guide its work internally and externally, Gill outlined three critical factors that lead to success for TransCelerate: leadership, focus and discipline. A strong level of commitment from the membership companies has allowed the consortium to develop the laser-sharp focus and key strategic priorities that have led to major accomplishments in risk-based monitoring and other areas. Another learning moment for TransCelerate was in seeing that many consortia often try take on more work than is feasible, which often leads to failures. Gill said this pattern drove TransCelerate to focus on a small number of projects and generate successes before branching out into further initiatives. Finally, discipline in project management, budgets and accountability throughout the partnership ensures delivery of the consortium’s goals and does not allow projects to linger, wasting the time and resources of its members.

Where Have We Been and Where are We Going?

Buckman-Garner reflected on the history of the consortium model in order to show what is possible and what the consortia world needs for the future. In 2004, FDA launched the Critical Path Initiative, and a 2006 report called for increased infrastructure in the areas of biomedical informatics, biomarker development and interoperable clinical trials. In the following 10 years, a variety of consortia were founded to engage in these efforts and draw upon the power of uniting multiple stakeholder groups. As a result, CDER built several tools to engage with these collaborative models, including the Critical Path Innovation Meetings, the Drug Development Tool Qualifier Program and dedicated program staff to facilitate technology transfer.

Biomarker development is a hot topic in the medical research arena, and Buckman-Garner presented an ideal model where individual data from labs or consortia could be aggregated and shared through a biomarker database to ease and speed up the biomarker qualification process. She noted, “The more that we are able to start to aggregate information, share that information and make that information available to support qualification review,” this information can have more utility for the FDA. This kind of data sharing and aggregation is applicable in other areas of research and could have many of the same benefits it would bring to biomarker development and qualification.

Buckman-Garner pointed out other ways to advance consortia, such as improving approaches for consortia to share information with each other, like the Consortia-pedia Catalogue. “This society for consortia to share improved approaches with each other is critical,” she noted. Developing a willingness to share information from both successful and failed studies through data repositories and enhanced adoption of data standards will help prevent consortia from duplicating efforts and wasting resources. Finally, Buckman-Garner is looking for new models to train future generations of regulatory scientists through interdisciplinary approaches and new reward systems that value team success over individual successes. With these improved approaches to collaboration, the medical research community can band together in an effort to deliver faster and better treatments for patients.

This strong team of speakers reflected on the power of collaborative research models and where consortia work can continue to improve the field in the future. FasterCures has been dedicated to enhancing collaboration since day one and will continue to analyze, enhance and facilitate partnerships for the benefit of all patients.

Related resources:

• Watch the archive of the webinar
• Find more than 400 consortia in FasterCures' Consortia-pedia Catalogue

Alzheimer’s Plaques Found in Middle-Aged People With Brain Injuries

Well shit, what stroke protocol is your doctor following to make sure this is not a result after your stroke? ANYTHING AT ALL?
Has your doctor/hospital done anything since these earlier research results?
Your 33% dementia chance post-stroke from an Australian study?  May 2012.
Then this study came out and seems to have a range from 17-66%. December 2013.
A 20% chance in this research.   July 2013.
http://medicalxpress.com/news/2015-01-scientists-heart-disease-clues-alzheimer.html

You're screwed because your doctor has done nothing. Ask and you shall find out how pathetic your doctor and hospital are. Maybe you need your brain garbage disposal system jump started.

dgnews.docguide.com/alzheimer-s-plaques-found-middle-aged-people-brain-injuries?
People with brain injuries following head trauma may have build-up of the plaques related to Alzheimer’s disease in their brains, according to a study published in the February 3, 2016, online issue of Neurology.
A corresponding editorial states that over the past decade the rate of emergency department visits related to traumatic brain injury (TBI) has increased by 70%. The editorial also says an estimated 3 to 5 million Americans live with a TBI-related disability.
“The study is small and the findings preliminary; however, we did find an increased build-up of amyloid plaques in people who had previously sustained a traumatic brain injury,” said David Sharp, MD, Imperial College London, London, United Kingdom.
“The areas of the brain affected by plaques overlapped those areas affected in Alzheimer’s disease, but other areas were involved,” he said. “People after a head injury are more likely to develop dementia, but it isn’t clear why. Our findings suggest TBI leads to the development of the plaques which are a well-known feature of Alzheimer’s disease.”
For the study, 9 people with an average age of 44 years who had a single moderate to severe TBI had positron emission tomography (PET) and magnetic resonance imaging (MRI) brain scans. The PET scans used a marker that detects plaques in the brain. The MRI scans used diffusion tensor imaging to detect damage to brain cells that occurs after TBI.
The brain injuries occurred between 11 months and up to 17 years before the start of the study. The participants were compared with 10 people with Alzheimer’s disease and 9 healthy participants.
Both the people with brain injuries and the people with Alzheimer’s disease had plaques in the posterior cingulate cortex, which is affected early in Alzheimer’s, but only those with brain injuries had plaques in the cerebellum. The researchers also found that plaques were increased in patients with more damage to the brain’s white matter.
“It suggests that plaques are triggered by a different mechanism after a traumatic brain injury,” said Dr. Sharp. “The damage to the brain’s white matter at the time of the injury may act as a trigger for plaque production.”
“If a link between brain injury and later Alzheimer’s disease is confirmed in larger studies, neurologists may be able to find prevention and treatment strategies to stave off the disease earlier,” said Dr. Sharp.
SOURCE: American Academy of Neurology

Does stroke location predict walk speed response to gait rehabilitation?

This is fucking pathetic that we are still asking questions like these. It means that every stroke survivor is an unregistered clinical trial of one for walking rehabilitation.  Because we have never had an objective stroke damage diagnosis.
https://ueaeprints.uea.ac.uk/55626/1/Does_Stroke_Location_Predict_Walk_Speed_Response_to_Gait_Rehabilitation.pdf
P. Simon Jones 1
, Valerie M. Pomeroy 2
, Jasmine Wang 3
, Gottfried Schlaug 3
, S. Tulasi Marrapu 1
, Sharon Geva 1
, Philip J. Rowe 4
, Elizabeth Chandler 2
,  Andrew  Kerr 4
,  Jean+Claude  Baron 1,5
,  for  the  SWIFT+Cast
investigators.
Affiliations:
1.Stroke Research Group, Dept of Clinical Neuroscienc
es, University of
Cambridge, UK
2.Acquired Brain Injury Rehabilitation Alliance, Scho
ol of Health Sciences,
University of East Anglia, Norwich, UK
3.Department of Neurology, Beth Israel Deaconess Medi
cal Center, Harvard
Medical School Boston, USA.
4.Bioengineering Unit, University of Strathclyde, Gla
sgow, UK.
5.Inserm U894, Sorbonne Paris Cité, Centre Hospitalie
r Sainte+Anne, Paris,
France
Running head: Stroke location and walking rehabilit
ation
Correspondence: 
Jean+Claude Baron
INSERM U894
2 ter rue d'Alésia
75014 Paris, France
tel: (33) (0)1 40788626 
fax: (33) (0)1 45807293 
email: jean+claude.baron@inserm.fr

Abstract
Objectives:  Recovery  of  independent  ambulation  after  stroke  is  a  major  goal.
However, which rehabilitation regimen best benefits each individual is unknown and
decisions are currently made on a subjective basis.  Predictors of response to specific
therapies would guide the type of therapy most appropriate for each patient. Although
lesion topography is a strong predictor of upper limb response, walking involves more
distributed functions.  Earlier studies that assessed the cortico+spinal tract (CST) were
negative, suggesting other structures may be important.
Experimental design: The relationship between lesion topography and response of
walking speed to standard rehabilitation was assessed in 50 adult+onset patients using
both  volumetric measurement  of  CST  lesion  load  and voxel+based  lesion+symptom
mapping (VLSM) to assess non+CST structures. Two functional mobility scales, the
Functional Ambulation Category (FAC) and the Modified Rivermead Mobility Index
(MRMI) were also administered. Performance measures were obtained both at entry
into the study (3+42 days post+stroke) and at the end of a six+week therapy. Baseline
score,  age,  time  since  stroke  onset  and  white  matter  hyperintensities  score  were
included as nuisance covariates in regression models.
Principal  observations:
CST  damage  independently  predicted  response  to therapy for FAC and MRMI, but not for Walk speed. However, using VLSM the latter  was  predicted  by  damage  to  the  putamen, insula,  external  capsule  and neighbouring white matter.
Conclusions:
Walk  speed  response  to  rehabilitation  was  affected by  damage involving the putamen and neighbouring structures but not the CST, while the latter  has  modest  but  significant  impact  on  everyday  functions  of  general mobility and gait. 

Functional and Motor Outcome 5 Years After Stroke Is Equivalent to Outcome at 2 Months

Well shit, this shows you how pathetic our stroke rehab protocols are. We seem to have nothing that helps chronic survivors. Everyone is relying on the normal spontaneous recovery in the first 6-12 months and not able to get their patients any farther than that. That is truly pathetic. These people should never be paid for this lack of results.
http://stroke.ahajournals.org/content/early/2015/05/07/STROKEAHA.115.009421.abstract

Follow-Up of the Collaborative Evaluation of Rehabilitation in Stroke Across Europe

1. Sarah Meyer, MSc,
2. Geert Verheyden, PhD,
3. Nadine Brinkmann, BSc,
4. Eddy Dejaeger, PhD,
5. Willy De Weerdt, PhD,
6. Hilde Feys, PhD,
7. Andreas R Gantenbein, MD,
8. Walter Jenni, MD,
9. Annouschka Laenen, PhD,
10. Nadina Lincoln, PhD,
11. Koen Putman, PhD,
12. Birgit Schuback, MSc,
13. Wilfried Schupp, MD,
14. Vincent Thijs, PhD and
15. Liesbet De Wit, PhD

+ Author Affiliations

1. From the Department of Rehabilitation Sciences (S.M., G.V.,W.D.W., H.F.), Interuniversity Centre for Biostatistics and Statistical Bioinformatics (A.L.), Department of Neurosciences (V.T.), and Experimental Neurology and Leuven Research Institute for Neuroscience and Disease (LIND) (V.T.), KU Leuven, Leuven, Belgium; Fachklinik Herzogenaurach, Herzogenaurach, Germany (N.B., W.S.); University Hospital Pellenberg, Pellenberg, Belgium (E.D.); RehaClinic, Zurzach, Switzerland (A.R.G., W.J., B.S.); University of Nottingham, School of Medicine, Nottingham, United Kingdom (N.L.); Department of Public Health, Vrije Universiteit Brussel, Brussel, Belgium (K.P., L.D.W.); University of Central Lancashire, School of Health, Preston, United Kingdom (K.P.); Laboratory of Neurobiology, Vesalius Research Center, VIB, Leuven, Belgium (V.T.); and Department of Neurology, University Hospital Leuven, Leuven, Belgium (V.T.).

1. Correspondence to Sarah Meyer, MSc, Department of Rehabilitation Sciences, KU Leuven, Tervuursevest 101, bus 1501, 3001 Leuven, Belgium. E-mail sarah.meyer@faber.kuleuven.be

Abstract

Background and Purpose—Recovery of patients within the first 6 months after stroke is well documented, but there has been little research on long-term recovery. The aim of this study was to analyze functional and motor recovery between admission to rehabilitation centres and 5 years after stroke.

Methods—This follow-up of the Collaborative Evaluation of Rehabilitation in Stroke Across Europe study, included patients from 4 European rehabilitation centres. Patients were assessed on admission, at 2 and 6 months, and 5 years after stroke, using the Barthel Index, Rivermead Motor Assessment Gross Function, Leg and Trunk function, and Arm function. Linear mixed models were used, corrected for baseline characteristics. To account for the drop-out during follow-up, the analysis is likelihood-based (assumption of missingness at random).

Results—A total of 532 patients were included in this study, of which 238 were followed up at 5 years post stroke. Mean age at stroke onset was 69 (±10 SD) years, 53% were men, 84% had ischemic strokes, and 53% had left-sided motor impairment. Linear mixed model analysis revealed a significant deterioration for all 4 outcomes between 6 months and 5 years (P<0.0001). Scores at 2 months were not statistically significant different from scores at 5 years after stroke. Higher age (P<0.0001) and increasing stroke severity on admission (P<0.0001) negatively affected long-term functional and motor recovery.

Conclusions—Five-year follow-up revealed deterioration in functional and motor outcome, with a return to the level measured at 2 months. Increasing age and increasing stroke severity negatively affected recovery up to 5 years after stroke.