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Emerging Areas of Stroke Rehabilitation Research in Low- and Middle-Income Countries

2019; Lippincott Williams & Wilkins; Volume: 50; Issue: 11 Linguagem: Inglês

10.1161/strokeaha.119.023565

1524-4628

Janet Prvu Bettger, Chelsea Liu, Dorcas B.C. Gandhi, PN Sylaja, Nitha Jayaram, Jeyaraj Pandian,

Cerebral Palsy and Movement Disorders

HomeStrokeVol. 50, No. 11Emerging Areas of Stroke Rehabilitation Research in Low- and Middle-Income Countries Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBEmerging Areas of Stroke Rehabilitation Research in Low- and Middle-Income CountriesA Scoping Review Janet Prvu Bettger, ScD, MS, Chelsea Liu, BA, Dorcas B.C. Gandhi, (PT), MPT (NPD), CMT, P.N. Sylaja, MD, DM, Nitha Jayaram, MBBS, MD and Jeyaraj Durai Pandian, MD, DM Janet Prvu BettgerJanet Prvu Bettger Correspondence to Janet Prvu Bettger, ScD, MS, Duke University, DUMC 2919, 40 Medicine Cir, Durham, NC 27710. Email E-mail Address: [email protected] From the Duke Global Health Institute, Duke University, Durham, NC (J.P.B.) , Chelsea LiuChelsea Liu Department of Epidemiology, Bloombesrg School of Public Health, Johns Hopkins University, Baltimore, MD (C.L.) , Dorcas B.C. GandhiDorcas B.C. Gandhi College of Physiotherapy and Department of Neurology, Christian Medical College, Ludhiana, Punjab, India (D.B.C.G.) , P.N. SylajaP.N. Sylaja Comprehensive Stroke Care Program (P.N.S.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India , Nitha JayaramNitha Jayaram Department of Physical Medicine and Rehabilitation (N.J.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India and Jeyaraj Durai PandianJeyaraj Durai Pandian Department of Neurology, Christian Medical College, Ludhiana, Punjab, India (J.D.P.). Originally published17 Oct 2019https://doi.org/10.1161/STROKEAHA.119.023565Stroke. 2019;50:3307–3313Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: October 17, 2019: Ahead of Print Seventy percent of strokes occur in low- or middle-income countries (LMICs), and the subsequent disease burden is greater than that of high-income countries.1,2 Demographic transitions, longevity, and trends of increasing burden in LMICs call for greater attention to rehabilitation services to improve stroke survivors' functional outcomes and quality of life.3 However, most LMIC healthcare systems are acute care oriented, urban located, and ill prepared to provide even essential stroke care with access to rehabilitation as defined by the World Stroke Organization "Global Stroke Services Guidelines and Action Plan."4 Beyond urban tertiary centers, rehabilitation services are scarcely available; there are 300 per 1 million. Rehabilitation needs globally are greater than the availability of services and trained practitioners; where present, quality of rehabilitation is far below evidence-based standards.6Rehabilitation guidelines are primarily based on studies from high-income countries, and uncertainty remains regarding the best management and treatment of activity limitations and participation restrictions due to stroke in LMICs. Understanding the availability of evidence generated in developing countries is critical for generalizability across LMICs. In this review, we describe the state of stroke rehabilitation research on service delivery interventions in LMICs and discuss emerging innovations to increase access to rehabilitation services.Rehabilitation Research in LMICsStroke affects people differently and the resulting activity limitations, participation restrictions, and trajectories for recovery vary. The process of stroke rehabilitation in LMICs is most likely to begin in the acute hospital where stroke or clinical expertise is most prevalent. Ideally, the process would include an assessment of rehabilitation needs, patient- and family-centered goal setting, and then a period of intervention with ongoing reassessment. However, the range in rehabilitation resources and expertise in LMICs limits the degree to which discipline-specific interventions (eg, gait training) or interventions for identified impairments (eg, swallowing disorders) can be scaled more broadly. The effectiveness of targeted physical rehabilitation strategies (treadmill training, motor imagery, mirror therapy, constraint-induced movement therapy, electrical stimulation, gait or balance training, taping, etc) for stroke survivors in LMICs was published recently.7 From this review of 62 studies, 46 conducted in the Asia-Pacific regions, 5 in Egypt, and 11 in Sub-Saharan Africa, authors noted that the level of evidence for stroke rehabilitation established in LMICs calls for a stronger rehabilitation workforce.Stroke survivors in LMICs are most likely to return home from the hospital with even less access to rehabilitation specialists than in the hospital; furthermore, their needs for optimal recovery will require interventions with several components aimed to reduce dependence and improve home and community participation. These complex interventions must consider local context including available personnel and infrastructure.8 Thus, we focused this scoping review on research of service delivery interventions that could reach stroke survivors after leaving the acute hospital, many of which are complex interventions that could involve a combination of strategies and therapeutic approaches to promote improved activity, participation, and quality of life.Review MethodologyWith guidance from a medical librarian, we searched PubMed and Google Scholar for stroke research published any date before December 31, 2018. We used 30 unique terms for rehabilitation, reference terms for developing countries, and each individual LMIC by name (Table) as defined by the World Bank.9 We included randomized controlled trials, quasi-experimental studies, systematic reviews, and meta-analyses of nonpharmacological service delivery intervention studies conducted in an LMIC for people aged 18+ years and within 6 months of their stroke. Authors independently screened titles and abstracts and then full texts to identify eligible studies that were categorized by intervention. Related interventions were grouped into emerging areas. Because of heterogeneity and inadequate reporting of outcome data, results were presented in a narrative summary.Table. Search TermsCategoryTerms (Fields Indicated for PubMed)StrokeStroke (MeSH)Rehabilitation"Early ambulation" (MeSH) or "exercise therapy" (MeSH) or "occupational therapy" (MeSH) or "recreation therapy" (MeSH) or "rehabilitation of speech and language disorders" (MeSH) or "physical therapy modalities" (MeSH) or "therapeutics" (MeSH) or "physical medicine and rehabilitation" (MeSH) or "rehabilitation" (MeSH) or "recovery of function" (MeSH) or "rehabilitation centers" (MeSH) or "independent living" (MeSH) or "early ambulation" (tiab) or "exercise therapy" (tiab) or "occupational therapy" (tiab) or "recreation therapy" (tiab) or "rehabilitation of speech and language disorders" (tiab) or "speech therapy" (tiab) or "speech and language therapy" (tiab) or "physical therapy" (tiab) or "physiotherapy" (tiab) or "physical medicine and rehabilitation" (tiab) or "physical medicine" (tiab) or "physiatry" (tiab) or "multidisciplinary rehabilitation" (tiab) or "rehabilitation" (tiab) or "rehabilitation centres" (tiab) or "rehabilitation centers" (tiab) or "independent living" (tiab) or "recovery of function" (tiab) or "mobilization" (tiab) or "mobility" (tiab) or "speech" (tiab) or "communication" (tiab) or "ambulation" (tiab) or "functional activities" (tiab) or "functional training" (tiab) or "activities of daily living" (tiab) or "allied health" (tiab) or "virtual rehabilitation" (tiab) or "telerehabilitation" (tiab)Reference terms for developing countries and individual LMICs"Developing countries" (MeSH) or "developing countr*" (tiab) or "developing nation*" (tiab) or "developing population*" (tiab) or "developing world" (tiab) or "developing econom*" (tiab) or "underdeveloped countr*" (tiab) or "underdeveloped nation*" (tiab) or "underdeveloped population*" (tiab) or "underdeveloped world" (tiab) or "underdeveloped nation*" (tiab) or "underdeveloped countr*" (tiab) or "underdeveloped population*" (tiab) or "underdeveloped world" (tiab) or "underserved countr*" (tiab) or "underserved nation*" (tiab) or "underserved population*" (tiab) or "underserved population*" (tiab) or "underserved countr*" (tiab) or "underserved nation*" (tiab) or "underdeveloped econom*" (tiab) or "underdeveloped econom*" (tiab) or "less developed econom*" (tiab) or "lesser developed econom*" (tiab) or "least developed econom*" (tiab) or "less developed nation*" (tiab) or "less developed countr*" (tiab) or "less developed population*" (tiab) or "less developed world" (tiab) or "lesser developed countr*" (tiab) or "lesser developed nation*" (tiab) or "least developed population*" (tiab) or "least developed countr*" (tiab) or "least developed nation*" (tiab) or "derived countr*" (tiab) or "derived nation*" (tiab) or "derived population*" (tiab) or "low income countr*" (tiab) or "lower income countr*" (tiab) or "lowest income countr*" (tiab) or "low income nation*" (tiab) or "lower income nation*" (tiab) or "lowest income nation*" (tiab) or "low income population*" (tiab) or "lower income population*" (tiab) or "lowest income population*" (tiab) or "middle income countr*" (tiab) or "middle income population*" (tiab) or "middle income nation*" (tiab) or "middle income econom*" (tiab) or "poor countr*" (tiab) or "poorer countr*" (tiab) or "poorest countr*" (tiab) or "poor nation*" (tiab) or "poorer nation*" (tiab) or "poorest nation*" (tiab) or "poor population*" (tiab) or "poorer population*" (tiab) or "poorest population*" (tiab) or "poor world" (tiab) or "third world" (tiab) or "transitional countr*" (tiab) or "transitional econom*" (tiab) or "transitional population*" (tiab) or "low gdp" (tiab) or "low gnp" (tiab) or "low gross domestic" (tiab) or "low gross national" (tiab) or "lmic" (tiab) or "lmics" (tiab) or "lami countr*" (tiab) or "Africa" (MeSH: noexp) or "africa" (tiab) or "Africa South of the Sahara" (MeSH: noexp) or "sahara" (tiab) or "Africa, Central" (MeSH: noexp) or "Cameroon" (MeSH) or "cameroon" (tiab) or "Central African Republic" (MeSH) or "african" (tiab) or "Chad" (MeSH) or "chad" (tiab) or "Congo" (MeSH) or "congo" (tiab) or "Democratic Republic of the Congo" (MeSH) or "Gabon" (MeSH) or "gabon" (tiab) or "Africa, Eastern" (MeSH) or "Burundi" (tiab) or "Djibouti" (tiab) or "Eritrea" (tiab) or "Ethiopia" (tiab) or "Kenya" (tiab) or "Rwanda" (tiab) or "Somalia" (tiab) or "Sudan" (tiab) or "Tanzania" (tiab) or "Uganda" (tiab) or "Africa, Southern" (MeSH) or "Angola" (tiab) or "Botswana" (tiab) or "Lesotho" (tiab) or "Malawi" (tiab) or "Mozambique" (tiab) or "Namibia" (tiab) or "South Africa" (tiab) or "Swaziland" (tiab) or "Zambia" (tiab) and "Zimbabwe" (tiab) or "Africa, Western" (MeSH) or "Benin" (tiab) or "Burkina Faso" (tiab) or "Cape Verde" (tiab) or "Cote d'Ivoire" (tiab) or "Gambia" (tiab) or "Ghana" (tiab) or "Guinea" (tiab) or "Guinea-Bissau" (tiab) or "Liberia" (tiab) or "Mali" (tiab) or "Mauritania" (tiab) or "Niger" (tiab) or "Nigeria" (tiab) or "Senegal" (tiab) or "Sierra Leone" (tiab) or "Togo" (tiab) or "Africa, Northern" (MeSH: noexp) or "Algeria" (MeSH) or "algeria" (tiab) or "Egypt" (MeSH) or "egypt" (tiab) or "Arab Republic" (tiab) or "Libya" (MeSH) or "libya" (tiab) or "Tunisia" (MeSH) or "tunisia" (tiab) or "Asia" (MeSH: noexp) or "asia" (tiab) or "Asia, Central" (MeSH) or "Kazakhstan" (tiab) or "Kyrgyzstan" (tiab) or "Kyrgyz" (tiab) or "Tajikistan" (tiab) or "Turkmenistan" (tiab) or "Uzbekistan" (tiab) or "Asia, Southeastern" (MeSH: noexp) or "Cambodia" (MeSH) or "cambodia" (tiab) or "East Timor" (MeSH) or "timor" (tiab) or "Indonesia" (MeSH) or "indonesia" (tiab) or "Laos" (MeSH) or "laos" (tiab) or "lao" (tiab) or "Malaysia" (MeSH) or "malaysia" (tiab) or "Myanmar" (MeSH) or "myanmar" (tiab) or "Philippines" (MeSH) or "philippines" (tiab) or "Thailand" (MeSH) or "thailand" (tiab) or "Vietnam" (MeSH) or "vietnam" (tiab) or "Asia, Western" (MeSH: noexp) or "Bangladesh" (MeSH) or "bangladesh" (tiab) or "Bhutan" (MeSH) or "bhutan" (tiab) or "India" (MeSH: noexp) or "india" (tiab) or "Far East" (MeSH: noexp) or "far east" (tiab) or "China" (MeSH: noexp) or "china" (tiab) or "Korea" (MeSH) or "korea" (tiab) or "mongolia" (MeSH) or "mongolia" (tiab) or "Caribbean Region" (MeSH: noexp) or "caribbean" (tiab) or "West Indies" (MeSH: noexp) or "west indies" (tiab) or "Cuba" (MeSH) or "cuba" (tiab) or "Dominica" (MeSH) or ""dominica (tiab) or "Dominican Republic" (MeSH) or "dominican republic" (tiab) or "Grenada" (MeSH) or "grenada" (tiab) or "Haiti" (MeSH) or "haiti" (tiab) or "Jamaica" (MeSH) or "jamaica" (tiab) or "Saint Lucia" (MeSH) or "saint lucia" (tiab) or "st lucia" (tiab) or "Saint Vincent and the Grenadines" (MeSH) or "saint vincent" (tiab) or "st vincent" (tiab) or "South America" (MeSH: noexp) or "south america" (tiab) or "Argentina" (MeSH) or "argentina" (tiab) or "Bolivia" (MeSH) or "bolivia" (tiab) or "Brazil" (MeSH) or "brazil" (tiab) or "Colombia" (MeSH) or "colombia" (tiab) or "Ecuador" (MeSH) or "ecuador" (tiab) or "Guyana" (MeSH) or "guyana" (tiab) or "Paraguay" (MeSH) or "paraguay" (tiab) or "Peru" (MeSH) or "peru" (tiab) or "Suriname" (MeSH) or "suriname" (tiab) or "Latin America" (MeSH) or "latin america" (tiab) or "Central America" (MeSH) or "central america" (tiab) or "Belize" (tiab) or "Costa Rica" (tiab) or "El Salvador" (tiab) or "Guatemala" (tiab) or "Honduras" (tiab) or "Nicaragua" (tiab) or "Panama" (tiab) or "Mexico" (MeSH) or "mexico" (tiab) or "Middle East" (MeSH: noexp) or "middle east" (tiab) or "Afghanistan" (MeSH) or "Afghanistan" (tiab) or "Iran" (MeSH) or "Iran" (tiab) or "Islamic republic" (tiab) or "Iraq" (MeSH) or "iraq" (tiab) or "Jordan" (MeSH) or "jordan" (tiab) or "Lebanon" (MeSH) or "Lebanon" (tiab) or "Syria" (MeSH) or "syria" (tiab) or "Syrian arab" (tiab) or "Turkey" (MeSH) or "turkey" (tiab) or "Yemen" (MeSH) or "yemen" (tiab) or "Europe, Eastern" (MeSH: noexp) or "eastern Europe" (tiab) or "Albania" (MeSH) or "Albania" (tiab) or "Bosnia-Herzegovina" (MeSH) or "Bosnia" (tiab) or "Herzegovina" (tiab) or "Bulgaria" (MeSH) or "Bulgaria" (tiab) or "Hungary" (MeSH) or "Hungary" (tiab) or "Macedonia [Republic]" (MeSH) or "Macedonia" (tiab) or "Moldova" (MeSH) or "Moldova" (tiab) or "Montenegro" (MeSH) or "Montenegro" (tiab) or "Republic of Belarus" (MeSH) or "Belarus" (tiab) or "Romania" (MeSH) or "romania" (tiab) or "Serbia" (MeSH) or "serbia" (tiab) or "Ukraine" (MeSH) or "Ukraine" (tiab) or "Indian Ocean Islands" (MeSH: noexp) or "indian ocean island" (tiab) or "indian ocean islands" (tiab) or "Comoros" (MeSH) or "comoros" (tiab) or "Madagascar" (MeSH) or "Madagascar" (tiab) or "Mauritius" (MeSH) or "Mauritius" (tiab) or "Seychelles" (MeSH) or "Seychelles" (tiab) or "Transcaucasia" (MeSH) or "Transcaucasia" (tiab) or "Armenia" (MeSH) or "armenia" (tiab) or "Azerbaijan" (MeSH) or "Azerbaijan" (tiab) or "Georgia [Republic]" (MeSH) or "georgia republic" (tiab) or "republic of georgia" (tiab) or "Pacific Islands" (MeSH: noexp) or "pacific island" (tiab) or "pacific islands" (tiab) or "Fiji" (MeSH) or "fiji" (tiab) or "Papua New Guinea" (MeSH) or "new guinea" (tiab) or "Vanuatu" (MeSH) or "Vanuatu" (tiab) or "Micronesia" (MeSH: noexp) or "micronesia" (tiab) or "Palau" (MeSH) or "Palau" (tiab) or "Samoa" (MeSH) or "samoa" (tiab)LMIC indicates low- and middle-income country.Although our attention to these highest levels of evidence may have inadvertently excluded important observational research or case series conducted in some LMICs, the intent was to identify tested service delivery interventions with measures of efficacy. Interventions with limited testing in LMICs but considered by the authors to have potential for increasing availability or access to rehabilitation were examined in more detail, incorporating findings from feasibility studies. Several subpopulations of stroke survivors are known to be underrepresented in research including women, patients of older age, with cognitive impairment, and lower educational attainment.10,11 We acknowledge that stroke survivor representativeness may be even further challenged for research in LMICs as a result of a range in factors from availability of transportation to participate to variable national guidance for inclusion and representation. As such, we have not addressed the populations studied in this review and focused the discussion on interventions.Emerging Areas of ResearchWe screened 447 clinical trials and systematic reviews of which 12 met inclusion criteria representing research conducted in Argentina, Brazil, China, Ghana, India, Malaysia, Mexico, Peru, Philippines, Taiwan, Thailand, and Turkey. Three intervention types emerged—home and community-based rehabilitation, caregiver engagement interventions, and digital health strategies—and, with the inclusion of feasibility studies, several models were identified within each type.Home- and Community-Based RehabilitationThe greatest opportunity for impact in LMICs may be when patients leave acute hospital care to return home. Evidence for home- and community-based models in LMICs or evaluated in other systematic reviews is described here in the context of lower resourced and geographically dispersed areas.Multidisciplinary Stroke TeamsMeta-analyses concluded that a multidisciplinary stroke teams approach working toward early supported discharge reduces length of hospital stay and increases independence in activities of daily living for survivors of mild-to-moderate stroke.12 Of 17 trials in this Cochrane review, 2 were from LMICs (one from Thailand and a pilot in India). Multidisciplinary stroke teams have been tested beyond early supported discharge. A comprehensive rehabilitation program that included patient and family education, cognitive and motor rehabilitation training, and medical follow-up until 6 months poststroke led to improvements in cognition and reduced anxiety and depression compared with usual care for 168 randomized stroke survivors in China.13 Although this was a small single-site study, the investigators attributed benefits to testing a complex multicomponent intervention with strategies that were in person, in home, and by phone and following a cyclical process of assessment, goal setting, intervention, and reassessment to support recovery. Simply put, the complexities of stroke must be met by complex interventions delivered over a long period of time. However, a 6-month intervention could be challenging when the rehabilitation specialist workforce is sparse and not integrated into all levels of care in the health system.14 Other approaches may need to be considered to facilitate greater access to specialists.Integrated Care PathwaysIn response to a lack of care coordination poststroke, experts from public and academic sectors in Malaysia partnered to develop Integrated Care Pathways for Post Stroke to be used by primary care.15 Algorithms guide rehabilitation in the community, risk factor monitoring, and primary care screening and management of swallowing problems. Operationalization of Integrated Care Pathways for Post Stroke required unique engagement across settings of multidisciplinary stroke teams including the discharging physicians and rehabilitation physicians, speech-language therapists particularly for swallowing disorders, community-based physio- and occupational therapists to address function, nursing in primary care, and family medicine specialists or medical officers to lead the care in the community. This model of program development is exemplary for LMICs as it leverages local leaders and resources to establish a contextually appropriate plan for service provision when access to specialists is limited. Investigators concluded that although Integrated Care Pathways for Post Stroke cost more than conventional care, it was cost-effective when considering quality-adjusted life-years gained.16 Effectiveness beyond this study sample of 151 stroke survivors in Malaysia is yet to be established.CHW ModelsThe evidence base for community health workers as part of team-based care and in support of disease management is strong.17 In India, the Association of People With Disabilities has included volunteer community health workers for the rehabilitation of rural patients with spinal cord injury under the supervision of a multidisciplinary stroke team but has not yet extended these services to stroke care.18 Field workers have been incorporated similarly in Nigeria, Philippines, and India for mental health services as a component of multidisciplinary care for persons with disabilities.19 These models are partly self-sustaining with internally generated revenue through drug receipts and partly funded by monetary and logistical (eg, transportation) support from nongovernment organizations and local municipalities. Although the effectiveness of this model is not yet tested with stroke patients, similar models of care that incorporate trained Community Health Workers to deliver community-based rehabilitation or provide support for home- and community-based activity developed for other populations may prove beneficial for stroke patients, caregivers, and the community.20Caregiver EngagementFamily caregivers are an important part of stroke rehabilitation in low-resource settings. In countries where organized rehabilitation is not widely available, family caregivers are the primary source of care for stroke survivors.21 Among nonpharmacologic stroke recovery trials in the past decades, Family-Led Rehabilitation After Stroke in India, RECOVER (Rehabilitation Through a Caregiver-Delivered Nurse-Organized Service Program for Disabled Stroke Patients in China), and a nurse-plus-caregiver strategy in Mexico evaluated the effect of task-shifting stroke rehabilitation to family members.22–24 Although none of the 3 trials found the intervention to be superior to usual care, they each identified that task-shifting rehabilitation is feasible and does not jeopardize stroke survivors' health.Although consistent involvement from a single primary caregiver may be difficult for families with shared caregiving responsibilities or migrant workers, a small quasi-experimental study in Thailand demonstrated favorable outcomes from an intense poststroke caregiver-training program. The 4-week program, delivered individually by a researcher to each caregiver, included 5 days of caregiver training in week 1, with review in weeks 2 and 3, to address stroke pathology, consequences, symptoms, prevention of complications, daily management of food, medicine, emotions and stress, information and training on patient mobility, fall prevention and rehabilitation, and social support. Investigators conducted follow-up home visits in week 4 to assess various aspects of poststroke patient care at home, post-test intervention evaluation, and to identify additional needs. The poststroke care skills checklist focused on 5 skill areas: feeding and aspiration prevention, pressure ulcer prevention and wound care, fall prevention, mobility, and rehabilitation. Community-based healthcare providers were available for further support to the caregivers and patients. When compared with routine care by community health centers, this elaborate training structure for caregivers produced improved poststroke care skills of the family caregivers and reduced patients' secondary complications and limitations in activities of daily living at 2 months.25 A notable strength of this intervention was the connectedness of the researcher to the local community health centers, reinforcing the value of care coordination with local resources.A triad approach to task-sharing rehabilitation activities—between rehabilitation specialists, general practitioners, and family caregivers—may be more potent as a team-based approach to community care. Working as a triad, the rehabilitation specialists could be involved periodically and a local healthcare provider or general practitioner could become more or less involved depending on caregivers' ability and time. The general practitioners could monitor both caregiver and patient progress, working under the guidance of the rehabilitation specialists, to slowly increase responsibility for daily activities to the patient for longer term self-management. Recognizing the importance of family caregiving poststroke and the limited rehabilitation resources in LMICs, future research could reconsider the partnership between healthcare providers, family, and patients and may need to plan differently around caregiver skills, patient needs, and expert guidance and coaching toward targeted goals.26Caregiving in low-resource settings can be time-consuming and strenuous. Studies from several countries including Brazil, Jordan, and Nigeria report that caregiving can lead to negative emotional, psychological, or physical health outcomes for the caregivers and poorer health of the stroke survivor.27–29 Despite encouraging results from research to date, studies often have small sample sizes, and there remain difficulties associated with accurately assessing caregiver burden in low-resource settings.26 These limitations affect generalizability to the large population of community-dwelling stroke caregivers. Research aimed to measure or address the burden experienced by caregivers is heavily neglected.30 Increased outreach to community-dwelling populations and continued efforts to generate real-world evidence are necessary to better understand the experience of stroke caregivers in LMICs.Digital Health TechnologyDigital health technologies have revolutionized rehabilitation medicine.31 The broad scope of digital health includes mobile health, wearable devices, health information technology, smartphone applications (apps), and telehealth.32 Unfortunately, the technological advances of high-income countries such as virtual reality (VR) and telerehabilitation have limited diffusion in LMICs because they are expensive, require a developed infrastructure, and need sustained expert assistance.33 These challenges also limit access and use of simpler (low tech) devices and assistive technology.34 Research is similarly constrained but evolving.TelerehabilitationTelehealth for stroke is more widely available for acute stroke treatment and community-based care and used most often to connect healthcare provider to healthcare provider. Telehealth platforms connecting rehabilitation specialists to another healthcare provider are less common. The RECOVER trial used video conferencing systems to connect rehabilitation specialists in urban areas to nurses providing rehabilitation in rural hospitals and followed up with ongoing mobile app–based communication between providers.35 A similar hub-and-spoke model for synchronous communication between clinicians was evaluated retrospectively in India. Teleneurorehabiltiation consultations were determined to be feasible and effective for collaborative care of patients in district hospitals. This approach was also less resource intensive than having rehabilitation specialists in each of the 4 spoke hospitals.36Telerehabilitation connecting providers directly to patients—in their homes or in groups at a community clinic, for example—will likely develop rapidly in LMICs. For example, a smartphone app plus teletherapist tested with 20 patients in Ghana was determined to be feasible according to a fidelity checklist and acceptable to survivors as determined with a 12-item instrument designed for the study to assess telerehabilitation experience.37 This 9zest Stroke Rehab App was developed for teletherapist–supported delivery of an individualized, goal-targeted 5-days-a-week, 12-week progressive exercise program. The program had 4 components (mobility and limb strengthening, dexterity for fine motor movements, seated and standing balance exercise, and walking endurance). Each component had levels of increasing difficulty, and activities performed were video recorded on the phone for review weekly with the teletherapist. Stroke survivors performed an average of 5.7 sessions per month for 25.5±16.2 minutes. The study faced challenges with internet connectivity but has the potential to increase remote availability and access to stroke rehabilitation expertise.Mobile HealthThe use of smartphones to educate patients and their families on stroke and deliver guidance for functional skills training without direct involvement of a therapist or rehabilitation specialist is emerging as the availability of internet service and smartphone ownership is on the rise in LMICs. Ownership across emerging economies is estimated to be 45%. Recent surveys indicate that ≤60% of people in Brazil and South Africa and 24% of people in India own a smartphone.38 Expecting continued growth, investigators in India developed the Care for Stroke app and found it was feasible with 60 stroke survivors and their caregivers in the early weeks after hospital discharge.39 The Care for Stroke application included instructions in the form of text and videos, with modules on stroke, home-based exercises, functional skills training, activities of daily living, and assistive devices. In Uganda, the short message service text intervention [email prot