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Background The aim of the International Stroke Recovery and Rehabilitation Alliance is to create a world where worldwide collaboration brings major breakthroughs for the millions of people living with stroke. A key pillar of this work is to define globally relevant criteria for centers that aspire to deliver excellent clinical rehabilitation and generate exceptional outcomes for patients. Objectives This paper presents consensus work conducted with an international group of expert stroke recovery and rehabilitation researchers, clinicians, and people living with stroke to identify and define criteria and measurable indicators for Centers of Clinical Excellence (CoCE) in stroke recovery and rehabilitation. These were intentionally developed to be ambitious and internationally relevant, regardless of a country’s development or income status, to drive global improvement in stroke services. Methods Criteria and specific measurable indicators for CoCE were collaboratively developed by an international panel of stroke recovery and rehabilitation experts from 10 countries and consumer groups from 5 countries. Results The criteria and associated indicators, ranked in order of importance, focused upon (i) optimal outcome, (ii) research culture, (iii) working collaboratively with people living with stroke, (iv) knowledge exchange, (v) leadership, (vi) education, and (vii) advocacy. Work is currently underway to user-test the criteria and indicators in 14 rehabilitation centers in 10 different countries. Conclusions We anticipate that use of the criteria and indicators could support individual organizations to further develop their services and, more widely, provide a mechanism by which clinical excellence can be articulated and shared to generate global improvements in stroke care.

Introduction Prehypertension is defined as blood pressure that is above the normal range but not high enough to be classed as hypertension. Prehypertension is a warning of development of hypertension as well as a risk for cardiovascular disease, heart attack and stroke. In the UK, non-pharmacological interventions are recommended for prehypertension management, but no reviews have focused on the effectiveness of these types of interventions solely in people with prehypertension. Therefore, the proposed systematic review will assess the clinical- and cost–effectiveness of non-pharmacological interventions in reducing or maintaining blood pressure in pre-hypertensive people. Methods and analysis This systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The databases/ trial registries that will be searched to identify relevant randomised controlled trials (RCTs) and economic evaluations include Medline, EMBASE, CINAHL, PsycINFO, CENTRAL, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, Cochrane Library, Scopus, and the International HTA Database. Search terms have been identified by the team including an information specialist. Three reviewers will be involved in the study selection process. Risk of bias will be evaluated using the Cochrane risk-of-bias tool for RCTs, and the Consensus Health Economic Criteria list for economic evaluations. Findings from the included studies will be tabulated and synthesised narratively. Heterogeneity will be assessed through visual inspection of forest plots and the calculation of the Chi2 and I2 statistics, and causes of heterogeneity will be assessed where sufficient data are available. If possible, we plan to investigate differential effects on specific sub-groups and from different types of interventions using meta-regression. Where relevant, the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE)

Background: The aim of the International Stroke Recovery and Rehabilitation Alliance is to create a world where worldwide collaboration brings major breakthroughs for the millions of people living with stroke. A key pillar of this work is to define globally relevant criteria for centers that aspire to deliver excellent clinical rehabilitation and generate exceptional outcomes for patients. Objectives: This paper presents consensus work conducted with an international group of expert stroke recovery and rehabilitation researchers, clinicians, and people living with stroke to identify and define criteria and measurable indicators for Centers of Clinical Excellence (CoCE) in stroke recovery and rehabilitation. These were intentionally developed to be ambitious and internationally relevant, regardless of a country’s development or income status, to drive global improvement in stroke services. Methods: Criteria and specific measurable indicators for CoCE were collaboratively developed by an international panel of stroke recovery and rehabilitation experts from 10 countries and consumer groups from 5 countries. Results: The criteria and associated indicators, ranked in order of importance, focused upon (i) optimal outcome, (ii) research culture, (iii) working collaboratively with people living with stroke, (iv) knowledge exchange, (v) leadership, (vi) education, and (vii) advocacy. Work is currently underway to user-test the criteria and indicators in 14 rehabilitation centers in 10 different countries. Conclusions: We anticipate that use of the criteria and indicators could support individual organizations to further develop their services and, more widely, provide a mechanism by which clinical excellence can be articulated and shared to generate global improvements in stroke care.

Background Stroke nurses are adopting extended roles to improve patient care due to limited numbers of vascular neurologists, however, little is known of this experience. We evaluated the impact of an internationally implemented fellowship education program to equip experienced stroke nurses, nationally and internationally, to undertake extended acute stroke roles. Methods We conducted semi-structured interviews with the following groups of individuals associated with the NET SMART Advanced Practice fellowship program: 1) Stroke nurse program graduates; 2) currently enrolled stroke nurse fellows; 3) local physician mentors; 4) service managers of program graduates. Interviews took place between February-August 2018 and were analysed using the Theoretical Domains Framework. Results Interviews were held with stroke nurses (n=11), mentors (n=4) and a service manager (n=1). Four themes were identified: 1) ‘The learning journey’- describing motivations for undertaking the training and course content; 2) ‘Organizational and professional change’- experiencing professional resistance to the new role, or lack of a suitable role to move into after program completion; 3) ‘What hindered the learning journey?’- small hospitals with low patient volume makes completion challenging; 4) ‘What helped the learning journey?’- a supportive team facilitated completion. Conclusion We found overwhelming skill development and professional growth by nurses, and this was echoed by mentors and managers. However, despite expanding their stroke-specific knowledge and skills, non-U.S.A. nurses faced systemic challenges in implementing their skills including lack of acceptance of extended nurse roles from wider professions.

Background: Suspected transient ischaemic attack (TIA) is a diagnostic challenge yet requires timely diagnosis for secondary stroke prevention. Aims: To understand variability of organisational processes, roles, education, and clinical decision-making in UK TIA services. Methods: Healthcare professionals were surveyed online in 2021 with descriptive data analysis. We conducted interviews (2021-2022) with a purposive sample. Three researchers thematically analysed interview data. Findings: Survey responses were received from 43 TIA services. 70% conducted remote consultations, 28% face-to-face, and 2% mixed. Different physician and roles, skills and experience provided TIA services. All services involved a consultant physician with experience in stroke. Ten interviews confirmed the survey results and highlighted variability regarding: clinical decision-making; service composition; resources; learning opportunities; and mode of consultation. Conclusion: Variability in TIA service workforce and service organisation influenced diagnostic decisions. The possible impact of such variability on clinical outcomes, and approaches to reducing it, require further research.

Introduction Around 40% of adults have pre-hypertension (blood pressure between 120–139/80–89), meaning they are at increased risk of developing hypertension and other cardiovascular disease-related conditions. There are limited studies on the management of pre-hypertension; however, guidance recommends that it should be focused on lifestyle modification rather than on medication. Self-monitoring of blood pressure could allow people to monitor and manage their risk status and may allow individuals to modify lifestyle factors. The purpose of this study is to determine the feasibility and acceptability, to both healthcare professionals and people with pre-hypertension, of blood pressure self-monitoring. Methods and analysis A prospective, non-randomised feasibility study, with a mixed-methods approach will be employed. Eligible participants (n=114) will be recruited from general practices, pharmacies and community providers across Lancashire and South Cumbria. Participants will self-monitor their blood pressure at home for 6 months and will complete questionnaires at three timepoints (baseline, 6 and 12 months). Healthcare professionals and participants involved in the study will be invited to take part in follow-up interviews and a focus group. The primary outcomes include the willingness to engage with the concept of pre-hypertension, the acceptability of self-monitoring, and the study processes. Secondary outcomes will inform the design of a potential future trial. A cost-analysis and cost-benefit analysis will be conducted. Ethics and dissemination Ethics approval has been obtained from London–Fulham NHS Research Ethics Committee, the University of Central Lancashire Health Ethics Review Panel and the HRA. The results of the study will be disseminated via peer-reviewed publications, feedback to service users and healthcare professionals, and to professional bodies in primary care and pharmacy.

Introduction: Long COVID (LC), the persistent symptoms ≥12 weeks following acute COVID-19, presents major threats to individual and public health across countries, affecting over 1.5 million people in the UK alone. Evidence-based interventions are urgently required and an integrated care pathway approach in pragmatic trials, which include investigations, treatments and rehabilitation for LC, could provide scalable and generalisable solutions at pace. Methods and analysis: This is a pragmatic, multi-centre, cluster-randomised clinical trial of two components of an integrated care pathway (Coverscan™, a multi-organ MRI, and Living with COVID Recovery™, a digitally enabled rehabilitation platform) with a nested, Phase III, open label, platform randomised drug trial in individuals with LC. Cluster randomisation is at level of primary care networks so that integrated care pathway interventions are delivered as “standard of care” in that area. The drug trial randomisation is at individual level and initial arms are rivaroxaban, colchicine, famotidine/loratadine, compared with no drugs, with potential to add in further drug arms. The trial is being carried out in 6–10 LC clinics in the UK and is evaluating the effectiveness of a pathway of care for adults with LC in reducing fatigue and other physical, psychological and functional outcomes at 3 months. The trial also includes an economic evaluation which will be described separately. Ethics and dissemination: The protocol was reviewed by South Central—Berkshire Research Ethics Committee (reference: 21/SC/0416). All participating sites obtained local approvals prior to recruitment. Coverscan™ has UK certification (UKCA 752965). All participants will provide written consent to take part in the trial. The first participant was recruited in July 2022 and interim/final results will be disseminated in 2023, in a plan co-developed with public and patient representatives. The results will be presented at national and international

Aim: This qualitative study explores with health professionals the provision of, and challenges for, post-discharge stroke care, focussing on eating, drinking and psychological support across India. Design: Qualitative semi-structured interviews. Setting: Seven geographically diverse hospitals taking part in a Global Health Research Programme on Improving Stroke Care in India Participants: A purposive sample of healthcare professionals with current experience of working with stroke patients. Results: Interviews with 66 healthcare professionals (23 nurses (14 staff nurses; 7 senior nurse officers; 1 Intensive Care Unit nurse; 1 palliative care nurse)); 16 doctors (10 neurologists; 6 physicians); 10 physiotherapists; 5 speech and language therapists; 4 occupational therapists; 4 dieticians; 2 psychiatrists; and 2 social workers) resulted in three main themes: Integrated inpatient discharge care planning processes; Post-discharge patient and caregiver role and challenges; Patient and caregiver engagement post-discharge. Conclusions: Discharge planning was integrated and customised, although resources were limited in some sites. Task-shifting compensated for a lack of specialists but was limited by staff education and training. Caregivers faced challenges in accessing and providing post-discharge care. Post-discharge care was mainly hospital-based, supported by tele-services, especially for rural populations. Further research is needed to understand post-discharge care provision and the needs of stroke survivors and their caregivers.

Introduction: Overweight and obesity are growing public health problems worldwide. Both diet and physical activity have been the primary interventions for weight reduction over the past decade. With increasing rates of overweight and obesity, it is evident that a primary focus on diet and exercise has not resulted in sustained obesity reduction within the global population. There is now a case to explore other weight management strategies, focusing on psychological factors that may underpin overweight and obesity. Psychological therapy interventions are gaining recognition for their effectiveness in addressing underlying emotional factors and promoting weight loss. However, there is a dearth of literature that has mapped the types of psychological interventions and the characteristics of these interventions as a means of achieving weight reduction and sustained weight reduction in adults with overweight or obesity. Methods and analysis: The review will combine the methodology outlined by Arksey and O’Malley with the PRISMA-ScR guidelines. A total of six databases will be searched using a comprehensive search strategy. Intervention studies will be included if participants are 18 years and over, classified as overweight or obese (≥BMI 25kg/m2), and have received a psychological therapy intervention. The review will exclude studies that are not available in English, not full text, none peer reviewed or combine a lifestyle and/or pharmacological intervention with a psychological intervention. Data will be synthesised using a narrative synthesis approach. Ethics and dissemination: Ethical approval is not required to conduct this scoping review. The findings will be disseminated through journal publication(s), social media, and a lay summary for key stakeholders.

Introduction: Urinary incontinence (UI) affects over half of people with stroke. It is unclear which methods are accurate in assessing presence and type of UI to inform clinical management. Diagnosis of UI based on inaccurate methods may lead to unnecessary interventions. The aims of this systematic review were to identify, for adults with stroke, clinically accurate methods to determine the presence of UI and type of UI. Method: We searched seven electronic databases and additional conference proceedings. To be included, studies had to be primary research comparing two or more methods, or use a reference test. Results: We identified 3846 studies with eight eligible for inclusion. We identified 11 assessment methods within the eight studies. Only five studies had sufficient comparator data for synthesis. Due to heterogeneity of data, results on the following methods were narratively synthesised: Core Lower Urinary Tract Symptom Score (CLSS), clinical history and physical examination, Barthel Activities of Daily Living Index, International Consultation Incontinence Questionnaire Short Form (ICiQ-SF) and urodynamic studies (UDS). Most studies were small and of low to medium quality. All reported differences in sensitivity, and none compared the same assessment methods. Conclusion: Current evidence is insufficient to support recommendations on the most accurate UI assessment for adults with stroke. Further research is needed.

Dehydration after stroke is associated with poor health outcomes, increased mortality, and poses a significant economic burden to health services. Yet research suggests that monitoring and assessment of hydration status is not routinely undertaken. In this commentary, we critically appraise a systematic review which aimed to synthesise the existing evidence regarding diagnosis and treatment of dehydration after stroke. The review discusses common measures of dehydration, describes studies evaluating rehydration treatments, and highlights the link between dehydration and poorer health outcomes in both human and animal studies. The reviewers suggest, future research should focus on determining a single, validated, objective measure to clinically diagnose dehydration in stroke patients. Research designs should include clearly defined patient characteristics, type and severity of stroke, and type and time point of dehydration measurement, to enable comparison between studies. Management of hydration status is a crucial element of acute stroke care which should be routinely practiced.

Background Person-centred community-based support services (PCCBSS) are an array of non-clinical services provided by organisations such as NHS Trusts, voluntary sector organisations, or local authorities. All PCCBSS involve an individual (variously known as a 'social prescriber’, ‘link worker’, ‘signposter’, ‘navigator’, ‘connector’ or ‘neighbourhood coach’) who talks with a service user before directing them to a range of relevant community sources of social, emotional, and practical support. Despite much recent investment in social prescribing, and its increased prominence within the policy context across England, little is understood about how PCCBSS are implemented. Research is required across different contexts to describe PCCBSS implementation; in particular, how social care providers successfully interact to support the implementation of PCCBSS, and how services responded to circumstances imposed by the COVID-19 pandemic. Purpose The aim of this post-implementation mixed-methods study is to explore how PCCBSS are implemented and become part of usual working practice. Using three services in North West England as case studies, we will examine factors influencing PCCBSS implementation and establish where there is learning for the wider adult social care system. Focus The study comprises two work packages (WPs): WP1: collecting data by reviewing service documents from three PCCBSS case studies; WP2: interviewing staff and service users (≤20 participants per PCCBSS); Key implementation data will be systematically abstracted (from WPs1&2) into a coding frame; combining contextual determinants from the Consolidated Framework for Implementation Research (CFIR) with process-related domains from Normalization Process Theory (NPT). Key outputs The findings from WP1 and WP2 will be presented in the form of an illustrated ‘pen portrait’, developed collaboratively with Applied Research Collaboration North West Coast ARC NWC public advisers, to illustrate how implementati

Introduction: Normalisation Process Theory (NPT) is widely used to explore how new healthcare practices are understood, enacted, reflected upon and embedded in usual practice, typically focussing on professionals’ behaviours. NPT is less commonly used to explore patients’ experiences during implementation of new interventions. The RETurn to work After stroKE (RETAKE) trial used NPT’s four constructs (coherence, cognitive participation, collective action, reflexive monitoring) in comparing experi-ences of stroke survivors who received Early Stroke Specialist Vocational Rehabilitation (ESSVR) with recipients of usual care (UC) only.Method: Semi-structured interviews with 44 stroke survivors (23 who received ESSVR and 21 UC participants). NPT underpinned data collec-tion and analysis.Results: RETAKE OTs helped participants in the ESSVR arm make sense of stroke, accept stroke-related limitations, and develop intervention understanding (coherence) more easily than most UC participants. RETAKE OTs typically involved all stakeholders in return-to-work (RTW) plans, facilitating co-operation and engagement (cognitive participation), whereas UC participants described poor co-ordination between services and limited or no focus on RTW. ESSVR participants completed individu-ally tailored work-related tasks, with RETAKE OTs mediating workplace adjustments and monitoring employment progress (collective action). In contrast, OT involvement in work preparation and employer negotiations for UC participants was rare. RETAKE OTs supported ESSVR participants to reflect on the appropriateness of RTW post-stroke or explore alterna-tives (reflexive monitoring). However, few UC recipients were supported to consider the suitability of their current work roles; consequently, some reported feeling ‘abandoned’ by health services.Conclusion: NPT was useful in exploring participants’ perspectives of a complex intervention in the RETAKE trial.

Introduction: Twenty-five percent of stroke survivors are of working age, yet the likelihood of successful return-to-work is low. This study compared experiences of recipients of Early Stroke Specialist Vocational Rehabilitation (ESSVR), an intervention to help stroke survivors return to work (RTW), with stroke survivors receiving usual care (UC) only. Method: Longitudinal case-study exploring experiences of stroke survivors who received ESSVR and those who received usual care (UC) only. Data were gathered using semi-structured interviews at 6 weeks, and 6- and 12-months post-randomisation. Findings were analysed thematically and mapped onto the APC model (Schwartz et al, 2018) which highlights three basic principles guiding RTW: Adaptiveness, Purposefulness and Cooperativeness in interactions between the person, the workplace and rehabilitation services. Results: Analysis indicates differences between ESSVR and UC participants’ RTW experiences. ESSVR participants report being supported to adapt to new circumstances following stroke by occupational therapists (OTs) providing tailored vocational rehabilitation (VR) and advocating for workplace adaptations and adjustments. Co-ordinated support ensured that stakeholders worked purposefully, with ESSVR OTs providing information and advice over 12 months. This facilitated cooperativeness, enabling a sustained RTW. In contrast, most UC participants reported little or no RTW support. They described a lack of communication and co-ordination between services and feeling ‘abandoned’ following discharge from community services, typically after 12 weeks. Conclusion: The APC model helped highlight the benefits of ESSVR. Specifically, stakeholders working together to adapt to stroke survivors’ changed abilities, being purposeful in delivery and receipt of VR support, and co-operating with OTs’ recommendations to facilitate successful and sustained RTW.

Introduction: Increasing evidence links poor oral health status, dysphagia and development of stroke-associated pneumonia (SAP). The aim of this study is to determine whether a phase 3, randomised controlled trial of oral healthcare (OHC) to prevent SAP in dysphagic acute stroke patients is feasible. Method: This is a randomised feasibility trial with parallel process evaluation. Using a factorial design, we plan to randomise 120 patients with acute stroke and dysphagia within 24 h of admission to either non-foaming toothpaste v 1% chlorhexidine gel and to either manual v powered brushing. Stroke unit nursing staff will receive standardised training to deliver the OHC treatments. Assessment of feasibility will include recruitment and set-up of sites, recruitment and retention of participants, adherence to allocated OHC treatment, acceptability and tolerability. We will also record incident SAP, antibiotic doses received, length of stay and modified Rankin score at 3 months. In the process evaluation we will focus on implementation of, and fidelity to, the OHC by undertaking focus groups at each site and employing behaviour change techniques to establish an implementation package. Results: The trial commenced on 31st August 2021 at 4 North West hospitals with final 3 month follow-up at the end of March 2023. Conclusion: We will establish whether feasibility progression criteria are met for a phase 3 trial, and whether further piloting is required.

After a stroke, physical activity can be key in enhancing the rehabilitation of patients and preventing a secondary stroke. In this commentary, we critically appraise a systematic review which investigated how different types of physical fitness training impact on the mental and physical conditions of stroke survivors. Cardiorespiratory, resistance and mixed training (especially when including walking) can improve key outcomes such as the balance and mobility of stroke survivors, but the most suitable type of training depends on the individual needs and aims of the rehabilitation process. More research is needed to understand how the effects of the different types of training vary by considering the time between stroke and intervention onset, stroke severity, and the dose of intervention.

Objectives Stroke survivors often have unmet physical, psychological and/or social concerns. Patient Concerns Inventories (PCIs) have been developed for other health conditions to address concerns. Our objective was to develop a PCI for stroke care. Methods This was a development study, including Modified Delphi study design, with academic and healthcare professionals with stroke care expertise. In Stage 1, a draft Stroke PCI (Version 1a) was created through identifying patient-reported concerns post-stroke from three previous studies and through expert panel discussions using Nominal Group Technique. In Stage 2, Version 1a was sent to 92 academic and healthcare professionals with stroke care expertise. Participants ranked their top 20 Stroke PCI items in order of importance and provided feedback. Rankings were converted into scores, and, with the feedback, used to amend the Stroke PCI. Two further rounds of feedback followed until consensus was reached between participants. A final draft of the Stroke PCI was created. Results In stage 1, 64 potential Stroke PCI items were generated. In Stage 2, 38 participants (41.3%) responded to the request to rank Stroke PCI items. The three highest ranked items were ‘Risk of another stroke’, ‘Walking’, ‘Recovery’. After three rounds of feedback and amendments, the final draft of the Stroke PCI consisted of 53 items. Conclusions A Stroke PCI has been developed using patient-reported concerns in previous studies and input from academic and healthcare professionals. Future work will involve gathering further feedback on the tool and exploring its acceptability and usability in a pilot study.

Background: There is limited information on long term outcomes after stroke in Sub-Saharan Africa (SSA). Current estimates of case fatality rate (CFR) in SSA are based on small sample sizes with varying study design and report high heterogeneity. Aims: We report CFR and functional outcomes from a large, prospective, longitudinal cohort of stroke patients in Sierra Leone and describe factors associated with mortality and functional outcome. Methods: A prospective longitudinal stroke register was established at both adult tertiary government hospitals in Freetown, Sierra Leone. It recruited all patients ≥18 years with stroke, using the World Health Organization definition, from May 2019 until October 2021. To reduce selection bias onto the register all investigations were paid by the funder and outreach conducted to raise awareness of the study. Sociodemographic data, National Institute of Health Stroke Scale (NIHSS) and Barthel Index (BI) was collected on all patients on admission, at seven days, 90 days, one year and two years post stroke. Cox proportional-hazards models were constructed to identify factors associated with all-cause mortality. A binomial logistic regression model reports odds ratio (OR) for functional independence at one year. Results: 986 patients with stroke were included, of which 847 (85.9%) received neuroimaging. Follow up rate was 81.5% at one year, missing item data was <1% for most variables. Stroke cases were equally split by sex and mean age was 58.9 (SD: 14.0) years. 625 (63%) were ischaemic, 206 (21%) primary intracerebral haemorrhage, 25 (3%) subarachnoid haemorrhage and 130 (13%) were of undetermined stroke type. Median NIHSS was 16 (9-24). CFR at 30 days, 90 days, 1 year and 2 years was 37.1%, 44.4%, 49.7% and 53.2% respectively. Factors associated with increased fatality were male sex HR:1.28 (1.05-1.56), previous stroke HR:1.34 (1.04-1.71), atrial fibrillation HR:1.58(1.06-2.34), subarachnoid haemorrhage HR:2.31 (1.40-3.81), unde

BACKGROUND AND AIM Safe and efficient acute stroke care services, effective training and and context -sensitive research and advocacy are key to reducing the high stroke burden in Africa. However, quantitative data is sparse on stroke care services, training and research priorities in Africa. We describe the status of acute stroke care services and unmask training and research needs in Africa. METHODS A 56-item, pre-tested, multi-lingual online survey tool adapted from the World Stroke Organization (WSO) Roadmap to delivering quality stroke care was sent to stroke experts in each African country through e-mail directories of national stroke organizations, the African Stroke Organization (ASO), the African Academy of Neurology (AFAN) and the WSO-Future Leaders African fellows. Data on stroke services, management guidelines, stroke research, stroke education and training were collected and analyzed using descriptive statistics. RESULTS We surveyed 54 but had responses from 45 (83%) African countries covering 95% of the population of Africa. Only 4% of respondent countries had a national stroke registry or national stroke surveillance system. Thrombolysis was available in 49% of countries, at an estimated 255 centers. 16% of countries had access to endovascular thrombectomy at 69 centers. National stroke-specific training programs were available for 11% of consultants, 9% of general medical practitioners and 4% of nurses. Reperfusion therapy was selected as the most important training need and national stroke registries as the top research priority. CONCLUSION Our study highlights core needs for stroke services improvement, capacity building, context - sensitive research and multi-level advocacy in Africa.