Evidence-Based Guidelines and Clinical Pathways in Stroke Rehabilitation-An International Perspective.

Thomas Platz

doi:10.3389/fneur.2019.00200

Abstract

A high societal burden and a considerable increase in stroke-related disability was globally observed over the last 3 decades, and is expected to continue implying a major challenge for societies around the word. Structured multidisciplinary stroke rehabilitation reduces stroke-related disability both in older and younger stroke survivors of either sex and independent of stroke severity. In addition, there is rapidly increasing evidence to support the clinical effectiveness of specific stroke rehabilitation interventions. Evidence-based guidelines help to promote best possible clinical practice. Inherent difficulty for their provision is that it takes enormous efforts to systematically appraise the evidence for guidelines and their regular updates, if they should not be at risk of bias by incomplete evidence selection. A systematic review of the pertaining literature indicates that the currently published stroke rehabilitation guidelines have a national background and focus and represent the health care situations in high-income countries. Societies around the globe would benefit from central evidence sources that systematically appraise the available evidence and make explicit links to practice recommendations. Such knowledge could facilitate a more wide-spread development of valid comprehensive up-to-date evidence-based national guidelines. In addition, the development of genuine international evidence-based stroke rehabilitation guidelines that focus on therapeutic approaches rather than organizational issues, could be used by many to structure regional or local stroke rehabilitation pathways and to develop their resources in a way that will eventually achieve effective stroke rehabilitation. Such international practice recommendations for stroke rehabilitation are currently under development by the World Federation for NeuroRehabilitation (WFNR).

Highlights

National guidelines that primarily focus on stroke rehabilitation [13,14,15,16,17] can provide comprehensive guidance on both organization and content issues relevant for stroke rehabilitation, and they provide answers that are adjusted to the regional health care system
While the “clinical question approach” can certainly be useful, it carries a risk for lack of scope, e.g., not simultaneously looking at the diverse other forms of arm rehabilitation therapies, and to skip relevant treatment options. Another stroke rehabilitation guideline from the U.K. [16] that more comprehensively looked into arm rehabilitation techniques came to a different conclusion and recommended with the highest level (A) “Repetitive task training is not routinely recommended for improving upper limb function.”
People around the globe can make use of the guidance that is available from existing stroke guidelines, both in terms of service set-up and organization as well as on how to therapeutically address specific problem that people are faced with after stroke

Summary

Introduction

National guidelines that primarily focus on stroke rehabilitation [13,14,15,16,17] can provide comprehensive guidance on both organization and content issues relevant for stroke rehabilitation, and they provide answers that are adjusted to the regional health care system. The U.S stroke rehabilitation guideline [13] explicitly takes the situation into account where immediately after a short acute care treatment intensive rehabilitation care is provided in inpatient rehabilitation facilities (IRFs), followed by skilled nursing facilities (SNFs), that provide “subacute” rehabilitation, yet without daily supervision by a physician, and other care structures available in the U.S the content of these guidelines has restricted validity outside their context, especially when health care system and organizational aspects are addresse

Results

Discussion

Conclusion