Stroke units: more trials needed.

Abstract

Meta-analysis by the Stroke Unit Triallists’ Collaboration [1] of 19 small trials ([2–19] and unpublished data of A. Svensson, P. Harmsen, and L. Wilhelmsen) shows that stroke units reduce mortality and dependency, compared with general medical wards. This may be because better medical management helps prevent fatal complications (e.g. pulmonary emboli, aspiration pneumonia) or because of geographical concentration of patients under multidisciplinary management, led by a trained consultant, where the needs of stroke patients are not overlooked in favour of those of more acutely ill patients [3]. Additional elements (staff training, nurse interest in stroke, education and involvement of carers, earlier onset of physioor occupational therapy) may also have contributed. However, the meta-analysis findings are hard to apply to everyday practice. First, many trials excluded patients still requiring optimal management—those without a hemiparesis or with a mild stroke [3, 4, 8, 9, 12], those with severe strokes [4, 8, 12, 13], a reduced level of consciousness [4, 8, 11, 12, 17], prior disability or stroke [4, 12, 17] and those resident in nursing homes [8, 15, 17]. However, patients without a hemiparesis might still have disabling neglect [20]. Even the mild stroke patient might benefit from early referral to occupational therapy allowing, perhaps, earlier discharge home. Those with severe strokes, which might include many with an initially reduced level of consciousness, benefit from well organized rehabilitation services on ring-fenced wards [14, 21], and about half of these patients, if elderly, might be expected to have additional disabling disorders such as osteoarthritis, dementia and Parkinson’s disease [21]. Mainstream clinical practice is to offer such patients, including those from nursing homes, a course of rehabilitation, as even modest gains (such as the ability to transfer with one instead of two people or to sit in a chair for several hours without falling to the floor) might make all the difference to the possibility of returning home and to quality of life, either at home or in care.