Intercollegiate Stroke Working Party 2016
Intercollegiate Stroke Working Party 2016
National Clinical Guideline on the Management of people with stroke (fifth edition)
Feedback form for comments on draft chapters
This form is for you to make any comments you wish on the draft guideline. It is designed to help us collate all comments.
Comments on the overall structure of the guideline, or on a particular chapter should be titled ‘general’ but specific marked examples would be helpful.
The guideline is in 7chapters and has numbered parts (e.g. 6.2, 5.3.2). Please specify the part you are referring to accurately, by number. If necessary add other detail. (e.g. 5.3.1 rec B, 4.2 para 2).
Always please:
- Make your comments or suggestions as specific but as short as possible
- Give any references (and justify anything outrageous!)
Please give your name and email contact.
Name / Jakko Brouwers, Sarah Tyson, Praveen Kumar, Stephen Ashford, Fiona JonesOrganisation / ACPIN (Association of Chartered Physiotherapists In Neurology)
Email /
Date/version / Peer Review 1 April – 22 April2016
Part / Comment
2.10 Goal setting / We oppose the recommendation that goals should be plainly ‘‘SMART’ –with achievement monitored using goal attainment scaling’ (GAS) as there are other methods of goal setting and goal scoring which are no better and no worse. It would be better to recommend the setting of goals which are meaningful to the patient and set in partnership with patient and relatives where appropriate. For these goals to be measured and evaluated in a standardised way.
Opinions for individually named approaches to goal setting can differ in terms of how each approach should be implemented. For instance, multiple variations on the original GAS approach (Kiresuk 1968) exist, such as: involving greater patient participation in goal selection (Cytrynbaum 1979; LaFerriere 1978;Malec1999; Turner-Stokes 2009); having the treating therapist rather than an independent third party select and re-evaluate the GAS goals (Cytrynbaum 1979; Turner-Stokes 2009; Willer 1976); using a different number of ’levels’ of goal achievement and a different scoring system than was originally proposed (LaFerriere 1978; Turner-Stokes 2010; Willer 1976), or using standardised rather than individualised wording to indicate the extent of goal achievement (Turner-Stokes 2009). Similarly, there is no one agreed ’SMART’ approach to goal setting; the ’SMART’ acronym has been interpreted to refer to a range of goal-related concepts, and there is no consensus regarding the ’correct’ interpretation of this approach (McPherson 2014; Wade 2009).
3.11 Positioning / Given the lack of evidence (+ve or –ve), the introduction of this section is worded very strongly. There is no evidence that positioning has any of the effects listed. So it would be more appropriate to stay that positioning to “thought to optimise recovery ….” And that it “can reduce ….”
It is not true that good positioning is essential to reduce respiratory complications. In fact, a systematic review (Tyson & Nightingale Clin Rehab 2004;18;863-871) showed that position had no effect on saturation levels (as a proxy measure of respiratory function) in stroke survivors unless they had a respiratory co-morbidity. So I suggest this sentence is changed to “Good position may reduce respiratory complications and avoid compromising hydration and nutrition…”
3.11.1 Recommendations
A / Positioning prevents long-term complications (if it does anything). There is no need for it to be assessed or specifically implemented completed within 4 hours of admission. 24-48 hours would be quite enough. There are much higher priority issues to deal with in the very acute stages.
3.12 Early mobilisation
Recommendations / The inclusion of the results of the AVERT trial are to be applauded, however, the introduction to this section is rather complex and difficult to follow, such that the main message is lost. Could it be simplified so that the main message that very early mobilisation is harmful is clearer? I would interpret the results as saying that it should stroke survivors who are having difficulty moving around should be mobilised (i.e. start getting out of bed) 24-48 hours’ post-stroke. That doing it before 24 hours could be harmful. And that when patients start to mobilise this should be for short period (e.g. 10 minutes three times a day initially). Again more aggressive mobilisation (e.g. 30 mins 6 x per day) may be harmful. If there is uncertainty, then surely it is better to err on the side of caution, and avoid the treatment that might harm (i.e. very early, very vigorous mobilisation).
Recommendation A – fair enough
Recommendation B- contradicts itself. 1st saying that mobilisation should occur within 24-48 hours (fair enough). But then goes on recommend how it should be done within 24 hours, having just said that it shouldn’t happen before 24 hours. Perhaps it is a type and the final sentence is meant to say “If mobilisation begins within 48 hours of onset …..”
General Chapter 4 / The more logical and structured framework for the guidance in Chapter 4 is welcome. Personally I find the removal of information about the evidence behind the recommendation unhelpful. It ought to be clear which recommendations are based on evidence (even if incomplete) and which is based on the working parties’ preferences/ beliefs, however, the way that such motor related impairments have been addressed in Chapter 4 is confusing and does not fit with the ICF framework which purports to be the basis for the overall guidelines structure.
4.2 Arm re-education. This title does not refer to an impairment or activity limitation. I think the working party are referring to arm (or upper limb) activity i.e. whether the patient can use their arm and hand in ever day life. It should be labelled as such. Interventions that focus on (re)learning are not the only ones with evidence of effectiveness, and relearning is only one way by which one could improve upper limb activity.
4.9 Mobility and motor control. The use of the term ‘motor control’ is unhelpful and rather antiquated. It is fallacious concept and not recognised in the ICF. The primary motor impairment for people with stroke is weakness. Weakness is the cause of the other problems listed in the section introducing motor control (lack of coordination of movement and a loss of selective movement). This is a separate concept to mobility which is about one’s ability to get around. Weakness incudes upper limb weakness as well as lower. As currently structured, this chapter doesn’t address upper limb weakness at all, even though it is the predominant cause of limited UL activity.
If the ICF is being followed properly for motor related difficulties (as it has been for communication and cognitive problems), then there should be sections on motor / movement related impairments i.e. Weakness, Range of Movement, Spasticity, Pain, Ataxia, Sensory Impairments, Subluxation. Then further separate sections on Mobility and Upper limb activity. The section on mobility should include Balance, Walking and Falls.
4.12.3 Shoulder subluxation and shoulder pain. Shoulder subluxation is not synonymous with pain, although it often co-occurs. Subluxation is a consequence of weakness and should be in the section on motor/movement impairments. Shoulder pain is usually MSK in origin, sometimes co-occurring with neuropathic pain, thus it is covered in the pain section. There isn’t a strong justification for a separate section.
4.15 Spasticity and contracture management. Again this has combined two separate concepts, which often co-occur but their management is not synonymous. They should be in separate sections: Spasticity and range of movement/ contracture.
4.2 Arm re-education / See also comments above about the structure of this section.
The statement that there is “no high-quality evidence for any arm re-education interventions currently used in routine practice” is unhelpful, and fairly meaningless without defining what one means by the “interventions currently used in routine practice”. We suggest this is either removed or reworded.
The importance attached to the strength of evidence and how these translate to the recommendations is inconsistent.
There is good evidence involving 1000’s of patients that using intensive practice of functional tasks improves function for people with mild to moderate UL weakness (i.e. those with some movement in their shoulder and fingers). There is limited evidence for mental imagery in conjunction with ‘usual care’ (as noted in the section on the evidence). Yet the recommendation for CIMT is negatively worked intimating that there are few occasions when it might be used, rather than the strongest evidence for any UL intervention is for CIMT. It is the best of the bunch, and so therapists should use it until evidence for anything better comes along. It really is not justified to continuing using interventions that (at best) probably don’t work instead of ones that (at worst) might not work terrifically well for everyone. The recommendation is unnecessarily discouraging in its wording. Removing the ‘only’ so it says “CIMT should only be considered in people with mild to moderate upper limb weakness (i.e. some movement in their shoulder and fingers)”. This is an accurate recommendation from the evidence and gives the positive message.
The recommendation that CIMT should only be used if the team has the necessary training and the patient is able to participate fully and safely is common sense, a given for all professionals and true for all recommendations. So why add it just for CIMT? Either remove it from here, add it to all recommendations or add it as a proviso in a summary to cover everything.
The recommendations for mental practice say that patients “should be taught and encouraged to use mental practice of an activity to improve arm function …”. This is clearly overstating the strength of the evidence (as explained in the section on the state of the evidence). At best one could recommend that mental imagery might be considered for those who have an aptitude for mental imagery (many people don’t have much imagination and can’t do it!) and when delivered by someone with suitable training and expertise. I would have thought it more appropriate to recommend that it is only used within a trial until the evidence about who would benefit from it and how it should be delivered is clearer.
Why have a section on NMES for the UL which then does not relate to a recommendation? I am sure space is at a premium. There isn’t enough evidence for UL FES/NMES to be included in the recommendations (other than possibly that it should only be used within a clinical trial) so there is no rationale for including it in the section on the evidence? If it is included, then all the other possible interventions for which there is insufficient evidence to recommend usage should be included
It is a serious omission that there is nothing about the evidence for exercise, or bilateral vs unilateral UL training in this section, as there should be recommendations regarding both. Why have they been ignored (when there is good evidence) when interventions with flimsy evidence like mental practice, robotics and UL FES have been included? This may relate to the muddled structure referred to above, but that doesn’t make it OK.
4.9 Mobility and motor control / See comments above about the structure of this section. The consequence of the onerous conceptualisation of motor impairments as motor control is encapsulated in the statement that “Recommendations on motor control remain based on Working Party consensus level evidence as we are not aware of research on this broad topic”. You are right, there isn’t evidence on ‘motor control’ because it is not recognised as a concept outside the UK and people who cling to a hierarchical model of motor control. There is, however, a large body of evidence on weakness and its treatment. Credibility of the guidelines is diminished by its omission.
There is good evidence that strengthening is effective (for most recent SR - VEERBEEK et al 2014 but also Ada et AusJPT 2006;52;4;241-248 and Hillier Cochrane Review 2010).
There should be recommendations in this regard. Strength/ weakness needs to be assessed using standardised measures such as the Motricity Index (NB the MI measures strength NOT motor control) and stroke patients with weakness (in a body part) should exercise. The evidence suggests exercise that combines strengthening, cardio-respiratory and functional exercises, are most effective.
4.9.2 Balance / Inclusion of the statement that using a walking aid for ‘light touch’ rather than weight bearing produces better results is untrue. The study referred to is a descriptive study of weight bearing and muscle activity. It merely shows that it is possible to get stroke survivors to put less weight through their stick by telling them to do so. It does not compare the effect of using a stick in different ways, It should be removed.
An AFO also improves balance and risk of falls in people with stroke and could be added to the recommendations - Tyson et al Clin Rehab 2013;27:9:785-791
4.9.4 Walking / The statement saying that “People who are not able to walk independently at the start of treatment do not seem to benefit from treadmill training (Mehrholz et al., 2014)” is correct, but incomplete. It would be helpful to include that task specific practice of walking using electro-mechanical devices is effective for non-ambulatory patients and enables a great proportion of stroke survivors to regain their mobility (Merholz et al Cochrane 2013 Electromechanical-assisted training for walking after stroke). Body weight supported treadmill training is more feasible to use and may also effectively support non-ambulant patients to regain their mobility (but not increase walking speed) more effectively than over ground walking (Ada et al Jof PT 2010;56;3:153-61)
Recommendation C – why not add “Using a treadmill exercise programmes such as the FAME programme, for example”? Direct readers to how to effectively achieve the effect they are looking for!!!
Recommendation E. See comments above. Why not combine this with recommendation C?
4.12.3 Shoulder pain and subluxation / See previous comments about combining these concepts.
Recommendation D about FES is not supported by the literature. It may be a WP recommendation but smacks of someone’s hobby horse. Why is the recommendation so specific and strongly worded based on for such flimsy evidence? At best one could say that further trials of FES are warranted but in the meantime FES for shoulder pain and/or subluxation should only be used within a trial.
4.13 Sensation / Again the strength of the recommendation is in contrast with the strength of the evidence and inconsistent with other areas of the guidelines.
How can one state that “Sensory discrimination training should be offered to people with sensory impairment after stroke, as part of goal directed rehabilitation” immediately after saying that “There is no strong evidence to support any particular passive or active intervention”?
4.15 Spasticity and contracture management / See previous comments about combining these concepts.
The statement that spasticity is common is immediately contradicted but the next sentence saying that it is found in 19-43% (i.e. a minority) of stroke survivors. It would be more accurate to say that, although it can be very troublesome for those who have it (particularly those with a paretic upper limb), spasticity is not as prevalent as commonly believed.