Hope on the Horizon: The Challenging Journey of Stroke Recovery in the UK
Introduction
The challenge of providing effective and affordable rehabilitation for stroke survivors in the UK, and indeed globally, is multifaceted. It involves the development, availability, and cost of safe and effective technology and services. We can't take the development of new medical technology for granted. The time and cost of taking an idea forward and creating a product are becoming increasingly significant. Developers of such technology need to imagine making a return on their investment, and this needs more than the assurance of a clinical need - it takes someone willing to pay.
Stroke is a significant global healthcare challenge affecting millions, but this alone will not drive technology development unless there is a likely path toward a return on investment. We, too, need the infrastructure for service delivery, whether by remote support or face-to-face training. However, recent advancements and research in technology-assisted rehabilitation offer promising solutions to these challenges. This article considers the challenge of supporting stroke survivors in their recovery journey when resources seem lacking. We point to some products we loved that never developed sustained sales and some that might.
In a perfect world
Let's imagine this for a moment. It's not a perfect world, and bad things can happen. But imagine that you survived a stroke, and now the healthcare service works with you to provide all the necessary rehabilitation you need to get your life back on track. You can't do all you used to physically speaking, but you know that no effort was spared to help you recover. You now have more independence than you first hoped, and life is going well again. The aim was to recover as much function as possible with intensive rehabilitation and compensate for whatever function was lacking using assistive products. You feel fortunate to have received support from the health service when needed. There was even continuity of care as you could continue your rehabilitation when you left the hospital and went home. Recovering from a stroke was not going to be a quick fix, but you felt empowered to take charge of your recovery.
Unfortunately, many persons who experience a stroke in the UK will not receive sufficient physical rehabilitation to achieve their recovery potential. They may have the potential to recover some function and achieve greater independence, but they will almost certainly not receive sufficient guidance or sustained therapy. Some private providers might offer to use intensive rehabilitation and advanced technology to encourage neuroplasticity, but this can be costly and unaffordable for the majority of stroke survivors. Even in the best scenarios, knowing how much recovery will be possible will be challenging. Rehabilitation is a field where promising a particular functional outcome is difficult. There is always some uncertainty.
What's the solution? We can't expect the NHS to be funded to the level that it can meet all expectations. The NHS is great at acute care. It can save your life when urgent action is needed. Once survival seems assured, we will find that rehabilitation is time-consuming, highly individualised, and still likely to deliver uncertain outcomes. No healthcare system is going to enjoy dealing with this challenge.
Various scenarios could be considered in response to this challenge. Perhaps stroke survivors need inexpensive yet effective technology that people can use at home. Alternative sources of finance might help some individuals access more effective technology. We can imagine accessing web-based methods to get cost-effective access to training and support.
Does the technology and services to help many stroke survivors already exist? Even if this is true, the acquisition cost can be a barrier.
The Incidence of Stroke in the UK
Stroke represents a global healthcare challenge. The incidence of stroke in the UK has been the subject of extensive study and analysis. According to the projections, the number of strokes per year in the UK is expected to increase significantly. In 2015, there were 117,600 strokes, and this number is projected to rise to 148,700 by 2025 and further to 186,900 by 2035, marking an increase of 59% over 20 years. The increase in stroke incidence is attributed to factors such as an ageing population and improvements in acute treatment, leading to better survival rates.
Regarding survival, the number of stroke survivors is also projected to rise. In 2015, approximately 950,200 people were living with the consequences of stroke, and this number is expected to increase to 1,424,100 by 2025 and to 2,119,400 by 2035. The survival rates post-stroke have improved over the years, which contributes to the increasing prevalence of stroke survivors. For instance, a UK General Practice Research Database study showed that 56-day mortality after the first stroke reduced from 21% in 1999 to 12% in 2008[6].
The Stroke Association reports that there are currently about 1.3 million stroke survivors in the UK. This is consistent with other sources that estimate around 1.2 million stroke survivors in the country. The improvement in survival rates is partly due to a reduction in the incidence of strokes and also thanks to greater awareness of symptoms, leading to quicker treatment and limiting the harm caused.
Despite the improvements in survival rates, stroke remains a leading cause of death in the UK. It is responsible for approximately 35,000 deaths annually, which equates to a life lost every 17 minutes. The mortality rate from strokes has decreased over time, with deaths related to stroke declining by 49% in the past 15 years. This decline in mortality is attributed to better prevention, earlier treatment, and more advanced treatment options.
Financial Impact of Stroke
The financial repercussions of stroke reach far beyond the immediate healthcare costs, impacting patients, their families, and the broader economy. Direct costs include hospital care, medications, and rehabilitation therapy. In contrast, indirect costs may encompass lost productivity, early retirement, and the need for long-term care, assistive technology, or alterations to living spaces to accommodate disability. In the UK, the cost of stroke to the economy is staggering, with estimates suggesting that it may exceed £26 billion annually. This figure encompasses healthcare expenses, informal care costs, productivity losses, and the psychological impact on stroke survivors and their caregivers.
“The costs of stroke to the UK economy - may exceed £26 Billion per year”
Compounding these expenses are the disparities in access to rehabilitation and advanced treatments that could potentially lessen the long-term financial burden on individuals and society. The high cost of cutting-edge technologies and therapies not covered by the NHS can place a significant strain on stroke survivors and their families, often leading to substantial out-of-pocket expenses. The economic strain is further exacerbated by the potential loss of income due to stroke survivors' decreased capacity to work, coupled with the caregivers' financial strain, who may need to reduce their work hours or leave employment altogether.
Addressing stroke's financial impact necessitates a multifaceted approach, including increased investment in prevention, early intervention, and accessible rehabilitation services. Enhancing support for research into cost-effective rehabilitation technologies and methods could also play a critical role in reducing the long-term economic burden of stroke on individuals and the healthcare system.
What the NHS can do
The NHS does not typically prescribe specific products for stroke rehabilitation in the way it prescribes medications. Instead, stroke rehabilitation in the UK is primarily focused on providing medical treatments, therapies, and support services tailored to the individual needs of stroke survivors. These include physiotherapy, occupational therapy, speech and language therapy, and psychological support. However, there are aids and equipment that can assist stroke survivors in their daily living and rehabilitation process by compensating for lost function.
For instance, the Stroke Association has partnered with Essential Aids to offer a variety of daily living aids designed to help stroke survivors with day-to-day tasks. These aids include bathroom and kitchen aids, adapted cutlery, non-slip mats, and gadgets to assist with dressing and other everyday activities. While the NHS does not prescribe these products, they are recommended resources that can support the rehabilitation and independence of stroke survivors.
Furthermore, the NHS guides stroke rehabilitation, emphasising the importance of a multidisciplinary approach that may involve different types of therapies and support based on the stroke survivor's specific needs. This approach is aimed at helping stroke survivors regain as much independence as possible, improve their quality of life, and reduce the risk of another stroke.
The Developers Challenge
Our firm is regularly sought out to represent developers of innovative technology in stroke rehabilitation. With decades of experience, we possess insights into addressing clinical needs. However, the scarcity of resources often hampers these ideas. No company can succeed in developing clinically effective products if they are financially unattainable. Even products with outstanding clinical functionality will falter if the financial infrastructure for their acquisition is lacking.
The RehaMove 2 FES unit can support mutliple applications useful in stroke rehab
Clinicians often lack a clear understanding of the costs of creating medical devices. While ideas might be abundant, transforming these ideas into marketable products is a challenge not suited for the faint of heart. The medical device sector is subject to stringent regulations to ensure patient safety, which is undoubtedly crucial. However, global regulatory frameworks have become increasingly cumbersome and fragmented. Developers in the UK aiming to market their products locally and across Europe must navigate distinct regulatory systems in each region, which introduces a significant cost barrier even before a single product reaches the market. In the 1980s, I believed global regulatory frameworks were moving towards harmonisation. Regrettably, this expectation has proven to be a misconception.
Over the years, we have dealt with some very clinically effective products that, unfortunately, never became commercially successful. Tailwind was an elegant upper limb exercise device that implemented a therapy protocol called BATRAC (Bilateral arm training with rhythmic auditory cueing). This allowed stroke survivors to carry out exercises at home that facilitated arm movement. The evidence for its use was good, and those who purchased it enjoyed good results. Unfortunately, it was a little too expensive for the majority to fund.
The ICone from Heaxel was a robotic exercise device that implemented the protocols for arm and shoulder exercise, which had been extensively researched. It encapsulated the protocols in a desktop package and used innovative remote management to allow it to be used at home. Once again, pricing made home use virtually impossible, and the company struggled to make sales.
A PRAFO can be used to resist drop foot during early stroke recovery
Over the years, we have had greater success with our RehaMove 2 FES unit. This was initially best known for its use as a component in our successful FES Cycling system. However, when using the system's Sequence Mode software, the stimulator supports many applications essential in stroke rehabilitation. We will shortly bring to market other FES systems that we believe can make a difference for many stroke survivors.
We have for many years offered versions of the PRAFO (Pressure Relief Ankle Foot Orthoses) designs that can be very effective in facilitating continuity of care. In the early days following a stroke, using a PRAFO design can best prevent heel pressure ulcers, common in immobile patients.
The PRAFO can also resist the common tendency to a plantarflexion deformity (drop foot) at the foot and ankle. By preventing this problem, the patient can likely be mobilised more quickly..
The NexStride product can also be a very effective and modestly priced rehabilitation aid for stroke. It uses novel techniques to encourage a normal walking pattern.
Amongst our product portfolio we have a couple of products that could be extremely helpful to stroke survivors but are likely to be too expensive for many people.
The Carbonhand from Bioservo Technologies is an innovative robotic glove that provides grip assistance when this has been affected by accident or illness. The Carbonhand has been revised in recent times to include an easy to don glove and methods on activating the grip function that are most suitable for stroke survivors.
The Tek RMD from Matia Mobility is a product that was initially developed with spinal cord injured individuals in mind. It allows persons with lower limb paralysis or weakness to move around in their envronment in a standing position which is superior for health and social engagement. The electric lifter now enables the Tek RMD to be used by stroke survivors - only the cost remains as a barrier to access.
Modifications to the Tek RMD have made it much more suitable for stroke survivors
Where the user is able to return to work with the adoption of a product, some government support may be available. However, for many charitable sources might be the only option for some of our more expensive products.
Web-Based and Smartphone-Enabled Interventions
Developing web-based and smartphone-enabled educational interventions, such as the 'Care for Stroke' application, represents a significant step forward in making rehabilitation more accessible and cost-effective. This application is designed for stroke survivors to manage physical disabilities following a stroke. It is based on eclectic treatment approaches to stroke rehabilitation, including motor relearning and functional neurodevelopmental frame of reference. The application aims to provide an affordable, accessible means of rehabilitation that can be used independently by stroke survivors, particularly in low- and middle-income countries (LMICs) where resources for stroke rehabilitation are limited.
Cost-Effectiveness of Home-Based Rehabilitation
Studies evaluating the cost-effectiveness of different rehabilitation methods have shown that home-based rehabilitation programs can be more cost-effective than conventional hospital services. For instance, a study found that providing home-based rehabilitation through Community Stroke Rehabilitation Teams (CSRT) is less costly and more effective than traditional hospital-based rehabilitation. This suggests that investing in home-based rehabilitation technologies and programs could significantly reduce costs while maintaining or improving the quality of care.
Virtual Rehabilitation and Telerehabilitation
Virtual rehabilitation and telerehabilitation have emerged as viable solutions to the challenges of distance and cost. These methods utilize virtual reality systems and online platforms to deliver rehabilitation services remotely. For example, a study on the use of home-based, telerobotic-assisted devices for rural veteran stroke survivors found significant improvements in functional ability and depression symptoms, with cost savings compared to clinic-based therapy. Similarly, virtual stroke rehabilitation programs have been recognized for their potential to provide equitable access to rehabilitation services, especially for those living far from urban centers.
Low-Cost Virtual Reality Systems
The development of low-cost virtual reality systems for home-based rehabilitation offers a promising avenue for making advanced rehabilitation technologies more accessible. Such systems can provide engaging, intensive therapy tailored to the individual's needs, leveraging neuroplasticity for recovery. However, challenges remain regarding recruitment, technical support, and ensuring continued use by patients[18].
Financial Assistance and Fundraising
Various sources of financial assistance and fundraising options are available for stroke survivors facing financial barriers to accessing rehabilitation technologies. Organizations like Help Hope Live and the Stroke Victor Recovery Fund (USA only) offer support for stroke patients through community-based fundraising, helping to cover the costs associated with stroke recovery, including therapy and rehabilitation equipment.
Conclusion
The technology to support stroke survivors in their recovery journey exists, and innovative approaches are making it more accessible and affordable. Web-based applications, virtual rehabilitation, and low-cost virtual reality systems present viable solutions to cost and remote support challenges. Financial assistance and fundraising initiatives also play a crucial role in making these technologies available to those who need them most. As these technologies and support mechanisms evolve, they promise to transform stroke rehabilitation, making it more inclusive and effective for survivors worldwide.
Reading
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