Helping Stroke Survivors with Evidence-Based Practice

 

Helping Stroke Survivors with Evidence-Based Practice By Peter G Levine
Everyone talks a big game with evidence-based practice (EBP) in stroke. You can't go to any occupational or physical therapy seminars without the term being thrown around like confetti. Beyond the platitudes, what is EBP? How can EBP be clinically implemented to help stroke survivors? Finally, what are the best resources to access EBP for stroke?

What Is Evidence-Based Practice?

Evidence-based practice was initially defined by David Sackett, a Canadian MD. (note: David Sackett passed this last May. RIP.) He put it pretty simply: EBP is the “…conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”
Of course, he was writing for medical doctors. So let's start there. Are medical doctors engaged in EBP? Typically, no. An article in Scientific American puts it this way:
"Only a fraction of what physicians do is based on solid evidence from Grade-A randomized, controlled trials; the rest is based instead on weak or no evidence and on subjective judgment. When scientific consensus exists on which clinical practices work effectively, physicians only sporadically follow that evidence correctly."  (Scientific American)

How Can EBP Help Stroke Survivors?

Let’s be clear, treating stroke survivors with EBP aids recovery from stroke. Using the best available treatment is what survivors want and what they demand. This notion, that many survivors actually have a pretty good handle on what works and demand it, may come as a surprise to many clinicians. Part of the reason clinicians don’t know that many survivors pine for more robust and evidence-based treatments is confusion caused by timing. Simply, once survivors realize that more could have been done, they are no longer under clinical/rehab care.

During the acute and subacute phases (generally from onset through the first 3-6 months), the survivor trusts the system. It is usually pretty soon after discharge from therapy that survivors say, “Wait a minute, why wasn’t this (or that or the other thing) used?”
It is true that some survivors “go with the flow” and accept the amount of recovery they have upon discharge for therapy, but many, many don’t. This group is often younger (<65), educated, and while they may have rather large physical challenges, intellectual capacity is intact. And as a group, they recognize where the system has failed them. Yes, they complain about managed care strangling resources. However, many survivors also complain about a lack of awareness by clinicians about which treatments are supported by research.
So how can clinicians, for whom stroke is only one of many pathologies they treat, keep abreast and implement emerging treatment options for stroke? Here is a simple way… keep it simple. And once you narrow the issue down to recovery, things get pretty simple. Why does it tend towards simplicity? It has to do with the way science operates. Most folks think science expands our knowledge, and it does. But it expands mostly by contracting. So, while for decades it was thought that treatment A, B, C, D, E, F, G, and H all worked to promote recovery, research has tightened the focus and suggests that only A and C work and that “I” (a new treatment) shows promise.
Here is an example from the VA recommendations:
Treatment Approach Recommendations:

1. Strongly recommend a comprehensive motor recovery program early on in stroke rehabilitation.
2. There is insufficient evidence to recommend for or against using neuro developmental training (NDT) in comparison to other treatment approaches for motor retraining following an acute stroke.
3. Recommend that motor recovery program should incorporate multiple interventions, emphasizing progressive difficulties, repetition, and functional task practice.
4. Interventions for motor recovery (including improving ambulation) should include cardiovascular exercise fitness and strengthening.
5. Consider using strength training as a component of the therapeutic approach in paretic patients.

 
OK, let’s break this down to one sentence:
Start early, skip the older unproven options, make it more difficult, more repetitive and more task-specific, and promote cardio and muscular strengthening.
And there you have it: what you thought worked, works.
 

What are the best resources about EBP for stroke?

Here are some other resources to help you separate the stroke-specific clinical wheat from the chaff:
Evidence-Based Review of Stroke Rehabilitation
Stroke Engine

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