Stroke prevention and control involve surveillance, screening, diagnosis, primary and secondary prevention, management in the acute phase, and poststroke rehabilitation. Innovative system-based solutions beyond these approaches, such as task-shifting and task-sharing, are needed to achieve better prevention and control. These solutions are discussed in detail in chapters 16 and 17 of this volume (Magee and others 2017; Joshi and others 2017).
Surveillance, Screening, and Diagnosis
Surveillance
Few LMICs have the necessary funding and resources either to establish surveillance networks or to register data for detecting health trends in the population. The World Health Organization recommends a stepwise stroke surveillance approach (STEPS Stroke) for collecting data and monitoring trends. STEPS Stroke recommends collecting three types of data: information on stroke patients admitted to heath facilities (step 1), number of fatal stroke events in the community (step 2), and estimated number of nonfatal stroke events in the community (step 3). A study synthesizing STEPS Stroke surveillance in nine sites in India, the Islamic Republic of Iran, Mozambique, Nigeria, and the Russian Federation showed that STEPS Stroke surveillance is possible and feasible in low-resource settings (Truelsen and others 2007).
Screening
Screening for stroke risk factors provides an excellent opportunity to identify and educate persons at high risk. It usually includes surveys of demographic and lifestyle information; blood pressure measurement; carotid bruit detection; cholesterol measurement; blood glucose tests; and education on warning signs or symptoms, such as transient ischemic attack, and heart-related symptoms, such as atrial fibrillation.
Similar to surveillance initiatives, a stepwise approach is suggested for screening. At a most basic level, screening for risk factors may include collection of information on demographics and lifestyle, such as diet, physical activity, and smoking or alcohol use. A second tier of screening might include data obtained from physical examination, including height, weight, girth, and blood pressure measurements. A final tier might include laboratory measures, such as blood glucose and cholesterol levels. In resource-poor settings, where clinical tests may be inaccessible and unaffordable, patient history and physical examinations are more cost-effective than laboratory measures (Olson and Roth 2007).
Congleton, Small, and Freeman (2013) report that in eastern North Carolina, where previous stroke mortality had been 12 percent higher than in the rest of the state, stroke prevalence and mortality declined after approximately 4,900 community outreach risk factor screenings were conducted between 2007 and 2011. The cost-effectiveness of national stroke screening has not been analyzed comprehensively in LMICs, but it is reasonable to assume that targeted or opportunistic screening would decrease the stroke burden in LMICs. China launched the Stroke Screening, Prevention, and Treatment Project in 2009 to establish a nationwide stroke screening network consisting of nearly 140 stroke screening centers in selected hospitals, aiming to standardize evidence-based stroke care throughout China and explore the need to establish an electronic national stroke registry. However, many LMICs have no stroke screening projects, which is likely attributable to limited resources and lack of awareness of the benefits of screening.
Diagnosis
The American Heart Association and the American Stroke Association introduced best-practice guidelines for stroke diagnosis that include patient history, physical examination, neurological examination and use of stroke scales, and diagnostic tests. Neurological examinations should be performed if patient history and physical examination are suggestive of a stroke, and the National Institutes of Health Stroke Scale or other standardized stroke scales can assist in estimating the severity of stroke. Brain imaging can distinguish ischemic stroke from intracranial hemorrhage and identify the subtype of stroke and often its cause; vascular imaging may identify the site and cause of arterial obstruction and also identify patients at high risk of stroke recurrence. Computed tomography (CT) scanning, magnetic resonance imaging, Doppler ultrasound, CT angiography, and magnetic resonance angiography are widely used in HICs to determine the subtypes and causes of stroke.
The most widely used strategy for stroke diagnosis is immediate CT scanning. However, the expense of CT equipment for health care facilities and the cost of individual use of CT scanning for patients are still high for low-resource countries and areas. Moreover, CT scanning is not sensitive for old hemorrhage, a condition that requires the use of other technologies such as magnetic resonance imaging and digital subtraction angiography, which may not be available in resource-poor countries. The need to develop and distribute accessible, inexpensive, and reliable diagnostic equipment and technologies continues to present a growing challenge to LMICs.
Primary Prevention
The main primary preventive approaches for stroke are the promotion and maintenance of a healthy lifestyle and blood pressure control. A healthy lifestyle includes not smoking (and stopping smoking for smokers); not engaging in binge drinking; being physically active; and eating a healthy diet characterized by adequate intake of fruits and vegetables, reduced intake of dietary trans fat, and reduced intake of sodium. Prevention strategies for CVD may target persons at high risk or whole populations. Although clinical guidelines recommend targeting persons at high risk as the primary strategy, most CVD events occur in individuals who are at low to moderate absolute risk of CVD; therefore, prevention strategies based on the high-risk approach might have a limited impact on reducing stroke risk in populations. Which strategy is more cost-effective remains debatable, and a more sensible approach may be a combination of the two.
Tobacco Control
Tobacco control is ranked as the most important of five priority interventions for preventing noncommunicable diseases (Beaglehole and others 2011). According to a microsimulation model based on Indian data, smoke-free legislation and tobacco taxation in combination could avert 25 percent of myocardial infarction and stroke if the effects of the interventions were additive (Basu and others 2013). These approaches are likely to be more effective than brief cessation advice provided by health care providers, mass media campaigns, and advertising bans. Cessation advice is considered the least-effective strategy at the population level.
High Blood Pressure Prevention and Control
Reducing blood pressure has been demonstrated to reduce the risk of stroke effectively. In a meta-analysis of 11 clinical trials on reducing blood pressure and stroke among Asian populations, a 10 millimeters of mercury (mmHg) reduction in systolic blood pressure was associated with a 30 percent reduction in risk of stroke, regardless of the antihypertensive agent used (renin-angiotensin blockers, calcium-channel blockers, or diuretics) (Yano and others 2013). Another meta-analysis involving 19 trials indicated that a 7 mmHg and 5 mmHg reduction in systolic and diastolic blood pressure, respectively, reduced the relative risk of stroke by 22 percent (Xie and others 2015).
All clinical guidelines and expert consensus statements on prevention of stroke place great emphasis on preventing and controlling high blood pressure. Both a health care provider–centered high-risk approach as well as population-based measures for preventing hypertension in the general population are needed. Many LMICs, such as Brazil, China, Mexico, and Thailand, have initiated nationwide programs for preventing and managing high blood pressure through a combination of public health, clinical, and health system approaches. Both monitoring and evaluation of the long-term cost-effectiveness of these programs are necessary, as are developing and refining evidence-based, feasible, sustainable, and specific measures to guide their implementation.
Sodium Reduction
A particularly cost-effective strategy for reducing blood pressure is to reduce sodium intake. Achievement of actual and sustained reduction in sodium intake remains a challenge for both researchers and policy makers because of the well-established difficulty of changing lifelong dietary habits. More emphasis is needed on programs that discourage younger generations from establishing high-sodium dietary patterns earlier in life.
The use of low-sodium high-potassium salt substitutes, a safe product commercially available for many years, remains useful for circumventing the need to change dietary habits. In HICs, more than 70 percent of sodium intake comes from processed prepackaged food; persons in HICs probably would not benefit from the use of salt substitutes as much as persons in LMICs, where the majority of sodium intake comes from salt added during cooking. A meta-analysis of six clinical trials found that salt substitutes reduce systolic blood pressure by an average of 4.9 mmHg and diastolic blood pressure by 1.5 mmHg in adults, compared with salt (Peng and others 2014). These trials on salt substitutes—to be substantiated in the future by larger trials on hard outcomes, such as a trial of 21,000 patients currently under way in rural China—suggest that a policy of subsidizing and promoting salt substitutes may be useful for reducing sodium intake, blood pressure, and stroke incidence in LMICs.
Pharmaceutical Treatments
In addition to lifestyle modifications, another mainstay strategy for primary prevention of stroke is the use of pharmaceutical means to address hypertension, dyslipidemia (high cholesterol), and atrial fibrillation. The most compelling evidence—from multiple randomized clinical trials or meta-analyses—recommends treating hypertensive patients primarily with thiazide-type diuretics, as well as angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, beta blockers, calcium channel blockers, or a combination, with the aim of achieving blood pressure goals set in the eighth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (James and others 2014). In patients with coronary heart disease or diabetes, the recommended treatment is a 3-hydroxy-3-methyl-glutaryl coenzyme-A reductase inhibitor (statin) medication, with the aim of reaching low-density lipoprotein–cholesterol goals set in the National Cholesterol Education Program guidelines (Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults 2001). In contrast, intensive glucose therapy in patients with type 2 diabetes did not significantly reduce the incidence of stroke or other macrovascular events, according to the ACCORD or ADVANCE trials (ADVANCE Collaborative Group and others 2008).
The awareness, treatment, and control rates of hypertension and statin use in LMICs are universally lower than in HICs. To close the gap between guidelines and practice, LMICs need to find innovative and effective strategies for overcoming many health system and socioeconomic barriers, such as the prevalence of curative, acute care–oriented systems with limited resources and capacity, to improve identification of those at risk and to develop more comprehensive medication formularies on public and private health and pharmacy insurance plans.
Polypill Use
Polypill was originally proposed in the early 2000s and is estimated to have reduced ischemic heart disease events and stroke by more than 70 percent each as, respectively, either a secondary prevention drug among persons with vascular disease (Yusuf 2002) or as a primary prevention measure (Wald and Law 2003). The concept of a fixed-dose combination drug has been controversial since its inception and sparked many debates and several clinical trials intended to test the efficacy of polypill in similar but slightly different formulations. Trials (TIPS, UMPIRE, and IMPACT) conducted in India, New Zealand, and three European countries (Ireland, the Netherlands, and the United Kingdom) focused on improving risk factors (Mohan 2009; Selak and others 2011; Thom and others 2013). Their results showed smaller-than-theorized improvements in blood pressure and lipid levels, but the relative and absolute benefits of polypill on clinical outcomes are likely to be larger in high-risk than in low-risk subgroups. However, the differences are not statistically significant.
Although these initial results are not as promising as expected, controversies regarding polypill are likely to continue given its multifaceted appeal for overcoming the problems of polypharmacy, low cost, and large anticipated effects. At the same time, unresolved issues with polypill include the need to define its optimal components and to evaluate the pharmacodynamics and pharmacokinetics of a multiple-component formulation. Ongoing and future trials and hard outcomes are needed to establish safety and effectiveness. The cost-effectiveness of such a strategy in LMICs also needs to be established. Meanwhile, a balanced view regarding its role in the primary prevention of stroke is warranted. Polypill use should not lead to reduced emphasis on healthy lifestyle measures because these are the mainstays of stroke prevention.
Atrial Fibrillation Control
Prevention is one of the best protections against stroke caused by recurrent atrial fibrillation. Antiplatelet compounds such as aspirin are indicated for atrial fibrillation patients with a low to moderate risk of thrombosis and can reduce the risk of stroke from atrial fibrillation by 20 percent to 25 percent. Anticoagulation using vitamin K antagonists (most commonly warfarin in the United States and some other countries and acenocoumarol and phenprocoumon in Europe) has been the treatment of choice for preventing embolic events in patients with atrial fibrillation and a moderate to high risk of thrombosis, reducing the risk of stroke by up to 62 percent (Finsterer and Stollberger 2008). However, warfarin has significant limitations, including bleeding, need for continued follow-up blood tests, and drug-drug interactions. Although newer anticoagulants such as rivaroxaban and dabigatran have been developed, they potentially cause significant bleeding.
Because of their limitations, effective use of warfarin or other anticoagulants has faced many barriers, especially in LMICs. In health resource–limited settings such as China, new oral anticoagulants were not found to be cost-effective because of their high price. The left atrial appendage is the site of thrombus formation in the majority of strokes associated with atrial fibrillation. Closure or exclusion of the left atrial appendage has emerged as an alternative therapeutic approach to medical therapy, but its safety and effectiveness are yet to be fully established.
Community-Based Education
Community education encompasses all approaches that are concerned with screening, awareness raising, health education on risk factors, ways to reduce disease risks, and other health-promotion activities conducted in communities. A systematic review of peer-reviewed articles published between 1999 and 2006 on the topic of public education for stroke prevention included 32 studies on educational programs. Seven educational programs were judged successful using the evaluation criteria. They included two large-scale programs and five narrowly targeted programs (Wilson and others 2007). A community-based intervention trial was conducted in two communities (one intervention, one control) in three cities in China. Regular health education and health-promotion activities were conducted between 1991 and 2000 in the intervention communities, but no special action was taken in the control communities. Over the 10 years of the intervention, incident risk of strokes decreased by 11.4 percent, 13.2 percent, and 7.2 percent, respectively, in the three intervention communities compared with controls (Wang and Shuaib 2007).
Digital Health Strategies
Digital health is a promising field that involves the use of new information and communication technologies to improve health care management for both providers and patients. So far, no clear consensus has emerged regarding its terminology or definition. Other terminology includes e-Health, telemedicine, and mHealth. In this chapter, digital health is used to encompass all related terms.
Digital health is often associated with improved clinical decision making and increased efficiency for health care providers. For example, electronic health records, which are replacing traditional paper-based health records, integrate and organize patient health information so that every health provider involved in a patient’s care can have the same accurate and up-to-date information.
The growing global burden of stroke requires innovative, effective, and widely available strategies for stroke prevention. Mobile technologies, such as the recently introduced Stroke Riskometer application (app), offer an opportunity to address these issues (Feigin and Norrving 2014; Parmar and others 2015). Digital health makes it possible to individualize interventions for physical activity and dietary behavior change. Some digital health apps have already been developed to address stroke prevention, based on the Framingham Heart Study stroke prediction algorithm; these apps have been enhanced by data on major risk factors for stroke. Users can identify their personal risk factors, their absolute risk of stroke, and their relative risk compared with persons of the same age and gender; knowledge of one’s relative risk may be more motivating for behavior change than knowledge of absolute risk. Digital health programs in LMICs have the potential to expand access to prevention and treatment services by using ubiquitous and low-cost communication infrastructure. However, more research on the effectiveness of digital health and best strategies for implementation is needed to harness its potential for stroke prevention and control.
Cost-Effectiveness
Few cost-effectiveness studies compare multiple prevention strategies in LMICs. A review of nine studies that evaluated 14 comparative strategies for CVD (both heart disease and stroke) in Argentina concluded that salt reduction in breads, antihypertensive treatment, mass educational campaigns, and polypill strategies could be considered cost-effective. However, the authors cautioned that the economic evidence available to guide CVD resource allocation in Argentina seems to be limited (Colantonio, Marti, and Rubinstein 2010).
Treatment during the Acute Stage
Ischemic Stroke
The evidence regarding treatment in the acute stage of stroke is limited and based on a few small randomized trials, extrapolation of results from larger trials, and two well-conducted nonrandomized studies (Rothwell, Algra, and Amarenco 2011). A combination of preventive treatments (antiplatelet agents, antihypertensive treatment and statins, and anticoagulation and carotid endarterectomy, as appropriate) started quickly in specialist units appears to be effective.
Carotid endarterectomy has been shown in randomized trials to be highly effective when done within two weeks after a nondisabling stroke, although there is uncertainty about the safety of the intervention in the first 48 hours. Additionally, two trials with a total of 40,000 randomized patients showed that oral aspirin within 48 hours of onset of major ischemic stroke reduced 14-day morbidity and mortality, mostly by reducing the risk of a recurrent stroke. However, intensive lowering of blood pressure during the acute phase of ischemic stroke was not found to reduce the risk of recurrent stroke or death.
Intravenous tissue plasminogen activator (tPA), administered within 4.5 hours of symptom onset, is the only therapeutic agent approved for achieving arterial recanalization in acute ischemic stroke. Current major guidelines recommend the use of a standard dose (0.9 milligram per kilogram of body weight; maximum of 90 milligrams) of tPA. However, the recommended dosage of tPA in Asian populations varies, partly influenced by the treatment costs of this expensive medicine and the perceived racial differences in treatment response. In Japan, the only approved dosage of tPA is 0.6 milligram per kilogram of body weight; one of the reasons for using such a low dosage is treatment response. Consensus regarding the optimal dosage of tPA is wanting, and ongoing trials should begin to demonstrate whether low-dose tPA could be effective and for which populations. Based on reported use, tPA for acute ischemic stroke is available to some patients in approximately one-third of countries globally.
Hemorrhagic Stroke
Results of data from 404 hemorrhagic stroke patients showed that early (within six hours of onset) intensive blood pressure–lowering treatment (target systolic blood pressure of 140 mmHg) attenuated hematoma growth for 72 hours. There were no appreciable effects on perihematomal edema (Anderson and others 2010). A larger trial based on 2,794 hemorrhagic stroke patients did not find that intensive lowering of blood pressure within one hour reduced the primary outcome of death or severe disability. Additional analyses indicated improved functional outcomes with intensive lowering of blood pressure (Anderson and others 2010).
Stroke Units
Organized inpatient stroke unit care is provided by multidisciplinary teams that exclusively manage stroke patients in a dedicated ward, with a mobile team, or within a generic disability service (a mixed rehabilitation ward). Stroke units have long been shown to be an effective care-delivery model that improves clinical outcomes for stroke patients. The Stroke Unit Trialists’ Collaboration published a series of Cochrane reviews on stroke units. This systematic review of randomized trials in 1997 indicated that stroke patients who were managed in an organized setting (stroke unit) were less likely to die, remain physically dependent, or require long-term institutional care, compared with patients managed in a conventional care setting (Stroke Unit Trialists’ Collaboration 1997). Further analyses showed that organized inpatient stroke unit care probably benefited a wide range of stroke patients in a variety of ways—for example, reducing death from secondary complications and reducing the need for institutional care through a reduction in disability. The review, published in 2002 and updated in 2007 and in 2013 (Stroke Unit Trialists’ Collaboration 2002, 2007, 2013), concluded that stroke patients who received organized inpatient care in a stroke unit were more likely to be alive, independent, and living at home one year after the stroke. The benefits were most apparent in units based in discrete wards. No systematic increase in the length of inpatient stay was observed. Evidence of care in stroke units is limited in LMICs, where establishing such units is a challenge in itself, possibly due to lack of specialists, capacity, and other system-level barriers. More translational studies are needed to assess whether and how stroke units can be implemented in resource-limited settings.
Secondary Prevention
Secondary prevention of stroke is of particular importance because of the high risk of recurrent stroke, which occurs in approximately a third of stroke survivors in five years. Evidence-based guidelines for secondary prevention stress the benefits of a healthy lifestyle, including a healthy diet, appropriate physical activity, and no smoking, similar to the guidelines described for primary prevention.
Blood Pressure Control
Control of high blood pressure remains the most important strategy for secondary prevention of stroke. Existing evidence shows that lowering blood pressure with lifestyle changes and antihypertensive medicines protects against stroke recurrence. No comprehensive data are available on how well blood pressure treatment has been achieved among stroke patients in LMICs; however, it is intuitively logical that the situation is worse in LMICs than in HICs, because of the higher prevalence of stroke, more limited access to high-quality health care, and lower affordability of medicine, especially in rural areas.
Antiplatelet and Lipid-Lowering Therapies
Antiplatelet and lipid-lowering therapies are effective treatments for secondary prevention of ischemic stroke. Major clinical guidelines for secondary prevention of stroke recommend aspirin as the mainline antiplatelet therapy and statins as lipid-lowering therapy. However, uptake has been low for aspirin and even lower for statins, especially in LMICs. A study of 4,782 ischemic stroke inpatients in urban China in 2006 showed that use of antiplatelet therapy and lipid-lowering therapy declined substantially after discharge, from 81 percent and 31 percent, respectively, in hospital to 66 percent and 17 percent, respectively, a year later. Unlike the controversy surrounding use of polypill for primary prevention, polypill for secondary prevention has special appeal in LMICs because of its relative ease of use, effectiveness, and low cost. How to overcome barriers in its production, distribution, and sustained use by patients is a key issue that needs to be addressed to reap its population-wide benefits.
Homocysteine-Lowering Therapy
Elevated circulating homocysteine level has been postulated as a risk factor for CVD. However, an updated Cochrane review published in 2013 that included 12 trials (4 new trials since the last review in 2009) found no support for homocysteine-lowering therapy in the form of vitamin B6, B9, or B12 supplements, either alone or in combination, for preventing cardiovascular events (Martí-Carvajal and others 2013). The review included 47,429 participants either with or without CVD, suggesting that the finding of lack of effectiveness may apply to both primary and secondary intervention to prevent myocardial infarction and stroke. New trials are underway in China to evaluate the combined effect of folic acid and B vitamins for secondary prevention of stroke.
Surgery for Carotid Stenosis
Surgical interventions for symptomatic or asymptomatic carotid stenosis may be one option for certain patients. The less-invasive carotid artery stenting was not inferior to traditional carotid endarterectomy. However, the cost is much higher for stenting than for endarterectomy. More evidence is needed to determine whether and under what circumstances surgical interventions for carotid stenosis are useful.
Self-Management and Family Support
Community-based self-management intervention—a promising strategy for addressing chronic conditions across the world—emphasizes patient responsibility and action in concert with community health care providers. Self-management in stroke involves conscious efforts by patients themselves to deal with stroke-induced impairments, threat of stroke recurrence, and challenges of long-term recovery. Patients require a combination of information, support, and education about behavior change, tailored to the beliefs, attitudes, and cognitions of those who have had a stroke, their social circles, and health care providers. Three key dimensions affect stroke self-management equally: individual capacity, support for self-management, and self-management environment. Each component has the potential to facilitate or hinder successful self-management.
Self-management interventions have been demonstrated to reduce the risk of stroke recurrence and to have a positive impact on the use of health care resources, which is of great significance for resource-scarce settings. However, the benefits of self-management are inconclusive. The latest systematic review reported that only six of nine randomized controlled studies and three of six nonrandomized trials found that benefits were associated with poststroke self-management (Lennon, McKenna, and Jones 2013). None of the trials was conducted in LMICs, further limiting conclusions for resource-poor settings.
Between 25 percent and 74 percent of stroke survivors require help with daily living activities from informal caregivers, often family members. Results from the London Stroke Carers Training Course (LSCTC), which is a systematic, structured, training program delivered in a stroke unit for caregivers, showed a reduction in caregiver burden, anxiety, and depression and an improvement in psychological outcomes for patients, when compared with usual care. However, the Training Programme for Caregivers of Inpatients after Stroke, a large-scale, robust trial, showed no significant differences between the LSCTC and usual care on any of the assessed outcomes. Currently, the RECOVER (clinicaltrials.gov registration number NCT02247921) and ATTEND (trial registration number ACTRN12613000078752) trials are being implemented in China and India to determine whether stroke recovery care at home given by a trained family member is an effective, affordable strategy for persons who have suffered a disabling stroke. The results of these two trials will provide strong evidence on the effects of caregiver training programs in LMICs.
Rehabilitation
Although stroke is experienced as an acute event, stroke survivors live with long-term consequences and often manage their resulting limitations and health status as a chronic condition. As the population of elderly stroke survivors increases, and the number of survivors with disability and chronic care needs grows, rehabilitation care and therapy will play an increasingly important role. Stroke rehabilitation can be provided in inpatient, home, and community-based programs and may include physical, occupational, speech, and recreational therapies. The availability of and access to rehabilitation services and care for patients making the transition from acute care hospitalization varies dramatically around the globe, especially in LMICs. Factors contributing to the limited availability and accessibility of rehabilitation services include poor physician knowledge of the role of rehabilitation; lack of a rehabilitation component in the standard of care; long interval from stroke onset to admission to rehabilitation; infrequent, unskilled, and short-lived provision of rehabilitation care; and inadequate public insurance or financial support for rehabilitation care. This section discusses both care delivery and discipline-specific rehabilitation interventions. summarizes various models of care delivery currently in practice.
Models of Care Delivery for Stroke Rehabilitation.
Physical, Occupational, or Movement Therapy
Several interventions to improve physical function in the upper or lower limbs and activities of daily living have been studied in LMICs. Studies examining physical therapy in LMICs showed that patient outcomes improved significantly over time, including as measured by the Barthel index, Mini-Mental State Examination, and Stroke Rehabilitation Assessment of Movement. The research to date demonstrates interest in examining the efficacy and effectiveness of physical rehabilitation and medicine; however, studies are often hampered by low quality and significant limitations.
Speech Therapy or Cognitive Rehabilitation
No individual studies were identified for “rehabilitation of speech and language disorders,” and systematic reviews have not identified any studies from LMICs that meet inclusion criteria for specific questions related to speech and language or cognition. Given that an estimated 67 percent of stroke patients experience cognitive challenges, such as decreased attention and poor recall, this gap in the evidence requires attention from researchers.
Cost-Effectiveness
Cost-effectiveness studies of rehabilitation services in LMICs are also lacking. Investigators from Thailand reported that the cost of the acute phase of care was higher than that of the subacute phase, with differences by disability level (Khiaocharoen, Pannarunothai, and Zungsontiporn 2012). Compared with conventional hospital care, home-based rehabilitation for ischemic stroke patients resulted in a greater number of patients avoiding disability at a lower cost. Despite large gaps in stroke rehabilitation research, studies have increasingly included rehabilitation outcomes or evaluations of rehabilitation and therapy services. There is also tremendous opportunity in stroke rehabilitation research, and the intersection of disciplines and policy agendas provides the ideal platform for continued growth and success.
