Stroke is a leading cause of acquired disability in adults. If secular trends continue it is estimated that there will be 23 million first ever strokes and 7·8 million stroke deaths in 2030 [1]. In 2008, out of 57 million global deaths, 17 million were due to cardiovascular diseases [2]. Stroke accounted for about one third of cardiovascular deaths (5·7 million deaths) and 46·6 million Disability Adjusted Life Years (DALYs) [3]. Burden of disease measured as DALYs is a composite measure of both morbidity and mortality of stroke and a good indirect indicator of the economic and social burden caused by stroke. With regard to the incidence, there has been a decline in high-income countries and a greater than 100% increase in stroke incidence in Low-and middle-income countries (LMIC) over the last four decades. Currently, the overall stroke incidence rates in LMIC exceed the level of stroke incidence seen in high-income countries, by about 20% [4]. Countries in Eastern Europe, North Asia, Central Africa, and the South Pacific have the highest stroke mortality and stroke burden [5].
At present, globally, there are about 650 million people 60 years of age and older, and by 2050, the number of people 60 years of age and older is forecast to reach two billion [6]. Ageing of populations, globalization, and urbanization are the powerful drivers of the stroke epidemic. A large proportion of strokes are preventable through population-wide control of modifiable risk factors; unhealthy diet, physical inactivity, tobacco use, and drug treatment to address hypertension, diabetes, and hyperlipidemia through a primary health-care approach [7-9].
It has been estimated that the proportion of stroke patients who are dead or dependent at six-months in the absence of interventions is about 62% [10]. A population study of follow-up of stroke survivors demonstrated that at five-years two-thirds had some neurologic impairment and disability, 22·5% had dementia, 15% were institutionalized, and 20% had experienced a recurrent stroke [11]. Poststroke disability disproportionately affects people from the poorest wealth quintiles and people in lower income countries.
Recent studies have shown that stroke-related disability may be substantially reduced by emergency treatment of acute stroke in dedicated stroke units and by appropriate management of transient ischemic attacks [12, 13]. Simple clinical scores are also available to improve prehospital diagnosis of acute stroke and risk estimation in patients with transient ischemic attacks [14]. If these tools can be incorporated in health education and physician training programs, more people will receive appropriate stroke care thereby reducing stroke related disability. Immediate access to diffusion magnetic resonance imaging, intracranial magnetic resonance angiography, and detection and management of severe carotid stenosis and atrial fibrillation can also contribute to improved outcomes. However, most of these services are not available to majority of people in LMIC [15].
For most stroke survivor's rehabilitation is essential to become economically active and to participate in civic life. Article 26, of the United Nations Convention on the Rights of Persons with Disabilities, calls for ‘appropriate measures, including through peer support, to enable persons with disabilities to attain and maintain maximum independence, full physical, mental, social and vocational ability and full inclusion and participation in all aspects of life’[16].
In developed countries the recovery process of stroke survivors is supported with stroke rehabilitation services. These services reduce disability and increase the chances of a person returning to their own home. A five-year follow-up of a six-month cohort of all discharges in a stroke rehabilitation unit showed that 76% of those who returned home were still at home 12 months later [17]. However, even across countries in the developed world stroke care and rehabilitation need improvement in order to minimize poststroke disability [18].
The World Report on disability [19] has documented strong evidence of many barriers that restrict participation of people with disabilities. They include negative attitudes toward disability, inadequate national policies and standards, lack of provision of services, problems with services delivery, lack of accessibility to built environments and public amenities, lack of involvement of people with disabilities in decision making in matters directly affecting their lives, and inadequate financial resources to address these barriers. Importantly, evidence presented in the WHO report suggests that many of these barriers are avoidable and the disadvantages associated with disability can be overcome through appropriate policy and structural changes.
The World Disability report recommends measures to: Enable people with disability, access to all mainstream policies systems and services; Invest in specific programs and services for people with disabilities; Adopt a national disability strategy and a plan of action; Involve people with disabilities in decision making; Improve human resource capacity to address the needs of the disabled; Provide adequate funding and improve affordability; Increase public awareness, understanding of disability, and improve data collection and research on disabilities.
Implementation of the recommendations of the WHO report requires engagement of different sectors – health, education, social protection, labor, transport, and housing – and different actors – governments, civil society organizations, professionals, the private sector, and people with disabilities. The World Report on Disability recommends that countries tailor their actions to their specific contexts and that in resource-constrained settings some of the priority actions, particularly those requiring technical assistance and capacity building, be included within the framework of international cooperation.
