Rehabilitation after stroke: summary of NICE guidance

Dear Sir,

The publication of the recent Stroke Rehabilitation Guidelines summarised by Dworzynski and colleagues (2013) [1], demonstrates that NICE recognises this as a significant area of practice, and one where improving access and quality of care is essential. However, whilst we welcome their commitment to addressing this topic, there are several issues underpinning these guidelines which need to be highlighted.

Firstly, much of the evidence cited in the NICE guidelines has been labelled as low quality and there is an overall impression that there is a dearth of evidence. However we would argue that this is unbalanced and fails to acknowledge the strengths in this field, where there has been an exponential increase in evidence in recent years. We believe this impression arises because of the inappropriate selection criteria set for selecting evidence. Research into many aspects of stroke rehabilitation is extensive, of high quality and provides answers to important questions. In particular, the virtual exclusion of Cochrane systematic reviews from the guidelines, in contrast to the recent RCP clinical guidelines on stroke published in 2012 [2], means much relevant evidence was discarded and the recommendations made therefore appear inadequately supported. The NICE stroke rehabilitation guidelines also restricted itself to studies exclusively on patients with stroke - yet for many rehabilitation interventions there is no rational reason to exclude evidence from studies on patients with other diseases who have the same problem.

Secondly, in view of the evidence available, we would dispute the need for a modified Delphi consensus survey. Indeed the scientific methodology surrounding the conduct of this survey was questionable. Many of the questions posed were inappropriate, unhelpful and not clinically relevant (for example, the question on which profession was the most important in the MDT). The actual expert sample used was not balanced in terms of professional background or areas of expertise. In our opinion it is therefore inappropriate to include this when other important high quality evidence was omitted.

Thirdly, we believe a guideline should provide clear guidance where possible. This requires statements that take the general form of ‘patients with this clinical problem should have this intervention’- and qualified by any defined considerations. The statement concerning cognitive functioning is an example of unhelpful ‘guidance’, thus:

“Use interventions for memory and cognitive functions after stroke that focus on the relevant functional tasks, taking into account the underlying impairment. Interventions can include.......” [1]

No clinically useful definition of which patients should be included is provided and the term ‘memory and cognitive functions’ makes little sense (memory is a cognitive skill). Providing lists of what ‘can’ be used is of no value as many treatments can be used; the purpose of a guideline is to advise stroke rehabilitation teams on which treatments should be used.

Finally, we are unclear about how the four research recommendations suggested by the Guideline Development Group were formulated. There seems to be no clear rationale for why these specific areas have been chosen and indeed NICE seems to have ignored the top priorities relating to life after stroke identified by Pollock et al [3]. Frankly it is doubtful that these four areas are the most pressing research questions facing stroke rehabilitation clinicians or stroke survivors and their carers.

These guidelines are important because of the status afforded by NICE. However we feel this has been a missed opportunity to improve the delivery of stroke rehabilitation in the UK as the guidelines will do little to support better clinical care for patients after a stroke. We hope that in any future rehabilitation guidance NICE will return to the approach it previously used when considering Multiple Sclerosis and Parkinson’s Disease and make greater use of published high quality Cochrane systematic reviews. In future rehabilitation guidelines it is essential that the scope is broad enough to meet the need for integrated care across agencies and services. There must also be a flexible, tailored approach to identifying all the relevant evidence in order to answer the questions posed.

Yours faithfully,

Professor Avril Drummond
Professor of Healthcare Research, University of Nottingham.
Avril.Drummond@nottingham.ac.uk

Professor Marion Walker
Professor of Stroke Rehabilitation, University of Nottingham.

Professor Derick Wade
Consultant in Rehabilitation Medicine, The Oxford Centre for Enablement.

Professor Pippa Tyrrell
Professor of Stroke Medicine, University of Manchester.

Professor Nadina Lincoln
Professor of Clinical Psychology, University Of Nottingham.

Professor Peter Langhorne
Professor of Stroke Care, University of Glasgow.

Professor Peter Sandercock
Professor of Medical Neurology, University of Edinburgh.

References

1. Dworzynski K, Ritchie G, Fenu E, Mac Dermott K, Playford ED. Rehabilitation after stroke: summary of NICE guidance. BMJ 2013;346:f3615

2. Intercollegiate Stroke Working Party. National Clinical Guideline for Stroke, fourth edition. London: Royal College of Physicians, 2012

3. Pollock A , St George B, Fenton M, Firkins L. Top 10 research priorities relating to life after stroke - consensus from stroke survivors, caregivers, and health professionals. Int J Stroke. 2012 Dec 11. doi: 10.1111/j.1747-4949.2012.00942.x. [Epub ahead of print]