A search of Ovid MEDLINE (1950–2007), EMBASE (1980–2007), Cochrane Central Register of Controlled Trials, and PsycINFO (1806–2007) electronic databases for clinical research in stroke and traumatic brain injury (TBI) yielded 48,208, 40,925, 6606, and 7133 publications, respectively (see Panel 1 for details on the search strategy). Analysis of these publications in English-speaking countries (Panel 2) shows a consistently high level of interest in applied brain injury research across the countries identified.

At this stage of our research and public health development in New Zealand, it seems important to understand the extend of the problem of brain injury in our country and to summarise and reflect upon existing gaps in the research on brain injury epidemiology, treatment, and rehabilitation and how these might be addressed in future research. Accounting for overlapping publications between the electronic databases, results in a total of 210 New Zealand originated publications in the field of stroke and 80 publications in the field of TBI published since 1806.

Stroke and TBI are leading causes of morbidity, disability, and mortality in New Zealand. Together they account for the second largest share of total disability-adjusted life years lost and premature mortality in New Zealand (8.5% and 11.7%, respectively), yielding priority to ischaemic heart disease only.1

Each year in New Zealand, around 7000–8000 people experience a stroke2 and 22,000–33,000 people experience a TBI.3 The costs to the country are substantial, around NZ$219 to $253 Million2,3 in direct costs alone. Stroke and TBI also contribute substantially to potentially preventable socioeconomic and ethnic inequalities in New Zealand.2,4,5

Epidemiological studies are still needed to: explore the causes of persisting ethnic disparities in stroke occurrence and outcomes in New Zealand; the prevalence of and risk factors for TBI; lifetime risks of stroke and TBI; predictors of various outcomes; and population awareness of these disorders and their risk factors. It is important to maintain and further advance the high standard of our stroke and TBI epidemiological studies as the only reliable source of data for evidence-based health-care planning and prevention that would contribute to reducing the impact of these devastating disorders at individual and population levels.

While the number of publications in applied stroke and TBI research in New Zealand and other countries are generally comparable, the number and scope of randomised controlled trials (RCTs) in this critically important area of research in our country and overseas are far from satisfactory. Over a 6-year period (1998–2003) there have been 13 registered, ongoing, or completed RCTs in the field of stroke or injury (any injury) in New Zealand (A Jull, personal communication, 2007).

Of the nine RCTs carried out in stroke/TBI patients in New Zealand that were published and cited in MEDLINE until now (not accounting for international multi-centre trials in which New Zealand centres were involved), eight were in stroke patients6–13 and only one was in TBI patients (a small trial evaluating effects of Tai Chi Ghuan).14

Of the eight RCTs in stroke, five were drug-related prevention or management trials7,8,10–12 and there were three small rehabilitation trials evaluating effects of gait management,6 shoulder pain prevention,9 and self-directed exercises.13

Over half of stroke15 and TBI16 survivors remain dependent on others for everyday activities, often with significant adverse effects on informal (unpaid) caregivers.17,18 Reducing the impact of stroke and TBI on caregivers as well as patients is therefore key to the maintenance of independence and quality of life for these groups with an associated reduction in health service usage.

With a paucity of industry funded drug trials in New Zealand, it is important to concentrate research on trialling practicable and affordable approaches to rehabilitation of these most debilitating neurological disorders. Rehabilitation efforts and expenditure have, to date, focused mainly on motor/language functioning and activities of daily living. However, the majority of stroke and TBI survivors experience ongoing disability, and the impact of existing rehabilitation efforts is often limited.

Innovative rehabilitation interventions are urgently needed to improve outcomes. For example, there is growing body of evidence to suggest that one of the most promising ways to improve outcomes in stroke and TBI survivors and their family caregivers would be to improve neuropsychological impairment via cognitive and behavioural interventions.19–23 There are, however, gaps in quantifying, applying, utilising, and translating such knowledge into policies and clinical and public health practice.3,24,25 Should these interventions prove to be effective, this may change the current practice of management of brain injury.

It is vitally important to prioritise research on the basis of their expected impact on the population health and make sure that those interventions selected for evaluation are tested in properly designed and executed clinical trials. In addition, interventions of proven effectiveness (e.g. constraint-induced movement therapy in stroke survivors)26 should be more widely used by rehabilitation specialists.

New Zealand has several stroke and TBI experts and academics of high national and international standing, strong traditions and expertise of good quality epidemiological studies and clinical trials, and an elaborated network of brain injury subject recruitment sites. However, many research groups work in isolation, there is no cohesive stream of applied brain injury research projects, workforce development and capacity building, especially within high priority groups.

Currently in New Zealand a gap exists between basic and applied neuroscience (e.g. a gap between identification and development of novel treatment/rehabilitation interventions by basic neuroscientists and their fast-track clinical testing by clinicians and clinical epidemiologists). To address these issues, a coordinated and supported comprehensive and sustainable brain injury research programme is urgently needed.

The experience of other developed countries indicates that the development and implementation of such a programme is best accomplished via specialised multidisciplinary research centres consisting of clinicians, public health physicians, clinical epidemiologists and basic neuroscientists (including experts in stroke, TBI, neurorehabilitation, and neuropsychology).

Recently the Health Research Council, Ministry of Health, and Accident Compensation Corporation (ACC) have announced strategic objectives and priority portfolios to encourage initiatives in the field of impairment, rehabilitation, and disability. However, practical realisation of these initiatives is a challenging multidimensional task that requires coordinated efforts of academicians (e.g. universities), government institutions (e.g. Ministry of Health, ACC), research charity organisations, and healthcare policy makers.

Whether we are ready to accept the challenge and further advance brain injury research in New Zealand to the benefits of our people remains to be seen.

Author information: Valery L Feigin, Associate Professor and Senior Research Fellow, Clinical Trials Research Unit, School of Population Health, Faculty of Health & Medical Sciences; Suzanne Barker-Collo, Senior Lecturer, Department of Psychology, Faculty of Science; The University of Auckland, , Auckland

Correspondence: Associate Professor Valery L Feigin, Clinical Trials Research Unit, School of Population Health, Faculty of Health & Medical Sciences, The University of Auckland, Private Bag 92019, Auckland, New Zealand. Fax: +64 (0)9 3737510; email: v.feigin@ctru.auckland.ac.nz