Authors’ reply to Enderby, Meteyard, and ThorntonBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6023 (Published 10 September 2012) Cite this as: BMJ 2012;345:e6023
- Audrey Bowen, senior lecturer in psychology1,
- Anne Hesketh, clinical senior lecturer in speech and language therapy1,
- Emma Patchick, trial manager1,
- Alys Young, professor of social work education and research2,
- Linda Davies, professor of health economics3,
- Andy Vail, senior lecturer in biostatistics4,
- Andrew F Long, professor of health systems research5,
- Caroline Watkins, professor of stroke and older people’s care, chair of UK Forum for Stroke Training6,
- Mo Wilkinson, visitor monitor1,
- Gill Pearl, speech and language therapist7,
- Matthew A Lambon Ralph, professor of cognitive neuroscience8,
- Pippa Tyrrell, professor of stroke medicine9
- 1HCD, Ellen Wilkinson Building, University of Manchester, Manchester Academic Health Science Centre (MAHSC), Manchester M13 9PL, UK
- 2Jean McFarlane Building, University of Manchester MAHSC
- 3Manchester Health Sciences Research Group: Health Economics, Jean MacFarlane Building, University of Manchester MAHSC
- 4University of Manchester MAHSC, R&D Support Unit, Salford Royal NHS Foundation Trust, Salford, UK
- 5School of Healthcare, University of Leeds, Leeds, UK
- 6Clinical Practice Research Unit, University of Central Lancashire, Preston, UK
- 7Speakeasy, c/o 2 Purbeck Drive, Bolton, UK
- 8NARU, University of Manchester MAHSC
- 9University of Manchester MAHSC, Salford Royal NHS Foundation Trust
It is encouraging to see the Royal College of Speech and Language Therapists supporting randomised controlled trials (RCTs).1 2 Meteyard worries that RCTs will not cope with the complexity inherent after stroke.3 However, many RCTs have demonstrated the effectiveness of a range of complex interventions for heterogeneous populations (for example, stroke unit care, occupational therapy).
As Enderby notes, the Cochrane review finds benefit of therapy compared with nothing. However, like us it also finds no benefit over attention control.4 So “some is better than none,”5 but we must be open minded about what is done and by whom. Despite Meteyard’s concerns we can rule out those activities provided only to the intervention group (such as one to one impairment based therapy). In the first four months of stroke they added nothing to the outcome for participants from any measured perspective.1
Meteyard is wrong to say that treatment was unconstrained and that we examined variation in current practice. Each site altered its previous practice by adopting manualised assessment and treatment pathways, tools, and techniques as agreed by consensus. As Enderby recommends, our therapists targeted therapy to those most likely to benefit and selected appropriately tailored interventions.
We are grateful to Enderby for quoting our cautionary warnings about misinterpreting the findings, especially given Thornton’s reaction.6 Our nested qualitative study showed people with stroke valued increased early support (regardless of whether therapy or control).7 Interaction with a good communicator may be as beneficial as formal therapy. We recommend evaluating reorganised early services that retain therapists to supervise increased time with less qualified staff, with therapists directly involved for persisting problems.
In response to Thornton,6 the funding supported a series of studies with more than 700 participants, including studies on developing patient centred outcome measures that have had good international uptake.8 9
Cite this as: BMJ 2012;345:e6023
Competing interests: See original article www.bmj.com/content/345/bmj.e4407.