Appraisal of Clinical Practice Guideline: European Stroke Organisation (ESO) guideline on motor rehabilitation

 One word; 'guideline' tells me this is going to be a COMPLETE FUCKING FAILURE! Guidelines do not guarantee recovery; protocols do! Are you that blitheringly stupid?

Appraisal of Clinical Practice Guideline: European Stroke Organisation (ESO) guideline on motor rehabilitation

bers located in Europe, India and New Zealand. Funded by: European Stroke Organisation. Consultation with: European Stroke Organisation. Approved by: European Stroke Organisation. Location: https://journals.sagepub.com/doi/10.1177/23969873251338142

Description: This guideline is intended to support patients with stroke to gain motor function, quality of life and independence. An expert working group used a Delphi approach to identify six critical areas that were each formulated into a research question, which followed a PICO approach (Population, Intervention, Comparator, and Outcome). A literature search with meta-analysis was performed for each research question. Key recommendations for motor rehabilitation to add to existing rehabilitation programs were:

• 1)
  ‘more’ hours of arm training (add 20 hours, three to five times/week over 4 to 6 weeks)
• 2)
  ‘more’ hours of gait training (add 20 hours, three to five times/week over 4 to 6 weeks)
• 3)
  ‘more’ intense gait training for chronic stroke patients, who are medically stable with no heart problems, to improve walking endurance (high intensity defined using heart rate reserve or walking at a faster than usual speed) (6 to 27 hours, three or more times/week over 8 to 12 weeks)
• 4)
  use of a transfer package (defined as behaviour change techniques to enable transfer of gains from treatment sessions to daily life) to enable upper limb therapy benefits to translate into daily-life use of the arm
• 5)
  group-based therapy in addition to individual training for the lower extremity to improve balance, walking speed and endurance
• 6)
  ‘more’ sit-to-stand training (high repetitions) to improve postural balance.

Commentary: Guideline development followed the standard operating procedures of the European Stroke Organisation, which are based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. The questions posed by the group used a PICO approach. Members of the group rated the outcomes so that six research questions became the focus of this guideline. The group set minimum criteria for clinical trials to be considered for inclusion to reduce the likelihood that this guideline would be influenced by small sample sizes and bias. What is quite exciting about this guideline is that there are several useful aids that physiotherapists can use to implement the recommendations. A plain language summary, highlight box with key recommendations, and implications for clinical research sections make this guideline easy for clinicians to digest and immediately apply recommendations to their clinical practice. Clear summary statements with suggestions for implementation when there is sufficient evidence, along with call out boxes in the results section of the evidence-based recommendation (or expert consensus statement if there was not enough evidence for a recommendation) are also helpful for clinicians. There are several limitations to consider. Like many guidelines that inform physiotherapy practice, the evidence is derived from studies with differing parameters, including comparison groups and assessments. Each meta-analysis includes a small number of studies (< 10), which means that recommendations about the specific dose of therapy for arm and gait training are based on limited evidence. Also, the recommendation for ‘more’ hours of training is unclear: it was based on previous research where 17 to 30 additional hours were provided to treatment groups and compared with control groups that received varying hours of treatment. There is no consistency in the published literature for what constitutes existing rehabilitation programs, which makes it challenging for clinicians to translate recommendations to their specific setting. As the existing rehabilitation program treatment hours are likely to differ between centres, adding treatment hours to a variable base will mean that patients with stroke will continue to receive inconsistent dosages. Lack of rehabilitation dose specificity is a critical gap for future research to address.

Provenance: Invited. Not peer reviewed.