Stroke rehabilitation clinical practice guidelines in Low and Middle Income Countries: a systematic review of quality & unique features

Introduction: Efforts towards reducing stroke burden have been an immense challenge. One important reasons could be the scope and quality of clinical practice guidelines (CPGs) developed for stroke rehabilitation in Low-and-Middle-Income-Countries (LMICs), restricting its translation to clinical practice. This systematic review aimed to assess the availability, scope and quality of CPGs for stroke rehabilitation in LMICs. Methods: Following PRISMA guidelines, CPGs for stroke rehabilitation in LMICs were searched across four major electronic databases (Medline, EMBASE, CINAHL and PEDro). Additional studies were identified from grey literature and a hand search of key bibliographies and search engines. The availability and content of the CPGs were narratively summarized and quality of de novo CPGs was analyzed using ‘Appraisal of Guidelines REsearch and Evaluation’ (AGREE) tools: version II & Recommendations Excellence (REX) version. . Features of contextualizations/adaptations of non-denovo CPGs were narratively summarized. Results: Twelve CPGs from 10 countries were included. CPGs from Pakistan, Sri Lanka, India, and China were developed de novo. CPGs from Kenya, Philippines, South Africa, Cameroon, Mongolia, and Ukraine were contextualized/adapted based on existing guidelines from high-income-countries. Most contextualized CPGs had limited stakeholder involvement, local health systems/patient pathway analyses. All ten countries included recommendations for physiotherapy, seven for communication, swallowing, and five for occupational therapy services post-stroke. Quality assessment using AGREE-REX and AGREE-II for de novo guidelines was poor, especially scoring low in development & applicability. Conclusion: Contextualized CPGs for stroke rehabilitation in LMICs were scarcely available and not meeting required quality. There is a need for development of context-specific, culturally-relevant CPGs for stroke rehabilitation in LMICs to improve implementation/translation into clinical practice.