Abstract
Stroke recovery and rehabilitation research has grown exponentially over recent decades. 1 Yet, several barriers continued to hamper rapid progress and clinical impact. The International Stroke Recovery and Rehabilitation Roundtables (SRRR) commenced their work in 2015 with the goal to provide consensus recommendations, which if implemented, could impact the trajectory of stroke recovery and rehabilitation research and clinical outcomes. Three roundtables (outputs published in 2017, 2019, and 2023) have delivered 13 consensus statements that provide recommendations related to specific taskforce topics based on research and clinical need (see Table 1). The roundtable agenda is now encompassed within the operations of the International Stroke Recovery and Rehabilitation Alliance. 2 The third roundtable effort (SRRR3) is the focus of this edition of Neurorehabilitation and Neural Repair. This editorial aims to bring together all roundtable efforts to highlight where they are having impact and future goals to enhance their impact in the field, as well as highlight key SRRR3 taskforce outputs.
Topics for Which Consensus Recommendations Were Established in the First, Second, and Third Stroke Recovery and Rehabilitation Roundtable efforts.
Across all roundtable recommendations, a common theme has been harmonization of terminology, definitions, and outcomes. Addressing the core of our work, we argued that “rehabilitation” as a blanket term for all therapy-based interventions post stroke was problematic, vague, and an impediment to progress. 3 Rehabilitation reflects a process of care, while recovery reflects the extent to which body structure and functions, as well as activities, have returned to their pre-stroke state. 3 The term “recovery” can be represented as both change (mostly improvement) on a given outcome achieved between 2 (or more) timepoints, and mechanism(s) underlying any observed change (improvement or decline). 3 We have established a timeline and associated terminology of stroke recovery phases 3 that harmonized what was meant by “acute,” “sub-acute,” and “chronic”. This work placed emphasis on the integration of knowledge about the biology of recovery 3 when discussing time course. We have established consensus definitions for a stroke recovery biomarker, 4 post stroke fatigue, 13 and active and inactive ingredients of stroke recovery interventions. 12 Concerning outcomes, consensus recommendations are available for stroke details, patient characteristics, and sensorimotor outcomes5,11,15; cognition 9 ; fatigue 13 ; and control group types. 12 Since the beginning, an important cross-cutting theme of SRRR consensus statements has been preclinical-clinical alignment, with many roundtables integrating their knowledge and skills to deliver recommendations that are relevant across the translational continuum. Together, this work is elevating the standard of stroke recovery research, increasing the collaborative nature of our work, and pushing our field closer to impactful clinical outcomes.
The implementation of harmonized terminology, definitions, and outcomes is beginning to be observed across evidence sources and demonstrates the impact of SRRR within our field and beyond. Within our field, collaborative groups such as ENIGMA Stroke Recovery and the European Stroke Organization (ESO) motor rehabilitation after stroke consensus-based definition and guiding framework 16 are adhering to sensorimotor outcomes, 17 and along with systematic reviews, for example, Hayward et al 18 and Stinear et al 19 , are integrating harmonized terminology of stroke recovery phases. We have seen non-government stroke organization funding calls encourage people to adhere to SRRR consensus statements and use these statements to inform gap analyses. 20 However, we still need adherence to the consensus recommendations to continue to grow, especially across federal agencies responsible for funding large scale national and international programs of stroke research. Outside our field, consensus recommendations are becoming increasingly common, with recommendations now available for other neurological conditions including Multiple Sclerosis. 21
Turning our attention to the latest round of consensus statements, SRRR3 addressed control comparator trial design, 12 fatigue, 13 non-invasive brain stimulation techniques, 14 and standardized measurement of balance and mobility. 15 Consistent with prior roundtable efforts, SRRR3 applied innovative methods that integrate discussion, ranking, and prioritization to deliver consensus recommendations. Along with producing consensus statements for the field, SRRR3 efforts, like prior roundtables, were global—including over 50 experts from more than 20 countries. All groups had an early career member/s who supported the activities of the group, and were exposed to the consensus work of SRRR and an internationally collaborative group. Highlights from SRRR3 taskforces are summarized. Firstly, the control comparator trial design taskforce developed a decision support tool (CONtrol DeSIGN [CONSIGN], freely available https://www.redcap.link/SRRR-CONSIGN) to address common control design challenges faced by trialists. This taskforce also defined each type of control and when it is useful. The fatigue taskforce produced a roadmap for future research and tackled 4 priority areas: (1) best measurement tools for research, (2) clinical identification of fatigue and potentially modifiable causes, (3) promising interventions and recommendations for future trials, and (4) possible biological mechanisms of fatigue. In a second paper from this taskforce, they expanded on biological mechanisms which has been published alongside the taskforce papers in this edition. 22 The brain stimulation taskforce identified outstanding translational bench-bedside barriers to provide a roadmap for use of transcranial magnetic stimulation and transcranial Direct Current Stimulation for stroke recovery and rehabilitation. To facilitate the implementation of their recommendations, a new SRRR3 Unified Non-Invasive Brain Stimulation Research Checklist was developed. Finally, the measurement of balance and mobility group established a standardized set of clinical measurement instruments for investigating lower limb motor function, sitting- and standing-balance, and mobility, along with kinetic and kinematic metrics, including their equipment, to monitor recovery of quality of movement during standing and walking post-stroke. Testing protocols were included in the output from this taskforce to ensure clinical tests are implemented consistently.
The international SRRR recommendations highlight novel approaches and research targets to accelerate progress toward new treatments for recovery post stroke. Ultimately, the collection of SRRR consensus recommendations should be seen as an important stride forward to improve the comparability between stroke recovery and rehabilitation studies, enable the creation of “big data” to help us better predict and manage heterogeneity in recovery post stroke, and improve development and testing of augmented treatment models across the different cross-cultural care systems in high-, middle-, and low-income counties. We urge readers to adopt them and work collaboratively to continue to shape the discourse in our field and the approach taken to address important recovery and rehabilitation research and clinical priorities.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: SRRR3 received financial support from Canadian Partnership for Stroke Recovery, the NHMRC Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (GNT2015705), and unrestricted educational grants provided by Ipsen Pharma and Moleac.