Evidence behind stroke rehabilitation
Stroke is a common and serious condition for which there is no routinely available curative treatment. Because of the high burden of disability and the lack of a widely applicable medical treatment, much of post-stroke care relies upon rehabilitation interventions. This article will discuss the evidence behind stroke rehabilitation interventions. but before doing so we need to define some terminology. Rehabilitation has a rather non-specific definition: “a problem solving process aiming at reducing the disability and handicap resulting from a disease”. In this article we will use a broad definition of rehabilitation, which includes any general aspect of stroke care (generally non-surgical, non-pharmaceutical interventions) that aims to reduce disability and handicap (that is, promote activity and participation). This definition avoids an artificial splitting of early (often termed “acute”) and later (“rehabilitation”) care; rehabilitation interventions are relevant from the onset of symptoms. The main focus will be on evidence about treatments as these are the most common questions posed by clinicians. CHALLENGES TO EVIDENCE BASED PRACTICE IN STROKE REHABILITATION Conducting methodologically rigorous evaluations of rehabilitation interventions is complex. Firstly, rehabilitation interventions are traditionally tailored by a therapist or nurse to meet the identified needs of an individual patient. As such they can be difficult to define and test within a randomised trial. Secondly, a key strength of the randomised trial can be that both patients and health professionals are blind to the treatment given. In a circumstance where a therapist is applying a manual treatment technique to a patient it is often impossible to achieve such double blinding, although blinding of outcome assessment is usually possible (single blinding). Thirdly, many rehabilitation interventions are targeted at ameliorating a specific body function or promoting a specific activity. It can often be difficult to find a clinically meaningful, reliable, valid measure of outcome that is sensitive to any changes occurring as a result of the intervention. It could be argued that the particular strengths of randomised trials in rehabilitation lie, not with the detailed evaluation of very specific treatment decisions, but with the evaluation of more general rehabilitation policies (for example, policies for preventing shoulder pain or bed sores). As a result of these limitations, most randomised trials in stroke rehabilitation are conducted in a single centre and are frequently too small to provide a reliable answer in their own right. We therefore need to include all relevant trials in rigorous reviews (systematic reviews) of the evidence. Such reviews may also help counter concerns that individual rehabilitation trials have poor generalisability and are only relevant to their local area or specific circumstances.
DEFINING AND EVALUATING STROKE REHABILITATION INTERVENTIONS
One of the first challenges in creating a framework of evidence for stroke rehabilitation is to have a mechanism for describing and discussing rehabilitation interventions. One simple approach is to classify them according to their levels of complexity. For example: * Service level—These are typically provided by more than one individual, each providing a complex package of care in a specific context and interacting with others in a complex way. Examples might include stroke unit interventions or early supported discharge services. Some of the most robust stroke rehabilitation evidence comes from trials of such complex interventions. However, there is often difficulty in interpreting and implementing such evidence. * Operator level—These interventions are typically provided by a single operator such as the therapist or nurse, who provides a complex package of care that could incorporate both the personal interaction between the therapist...
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