Intended for healthcare professionals

Rapid response to:

Practice Guidelines

Rehabilitation after stroke: summary of NICE guidance

BMJ 2013; 346 doi: (Published 12 June 2013) Cite this as: BMJ 2013;346:f3615

Rapid Response:

Re: Rehabilitation after stroke: summary of NICE guidance

Dear Sir,

We are grateful to Dworzynski et al (1 July, 2013), for their very detailed response to our letter (20 June, 2013). Whilst it is not our intention to prolong the debate, we feel that we need to address some of the points raised. Thus;

1. It is our contention that the ‘standard NICE methodology’ was not appropriate in this guideline and therefore referring us to further information is not helpful.

2. We believe that GRADE was used inappropriately.

3. The response regarding excluding Cochrane systematic reviews does not make sense; how much of a ‘match’ was needed?

4. Dworzynski et al said ‘This is usual practice for NICE guidance unless there is a good reason to consider evidence from another population’. We believe there was good reason as it is not justifiable to address rehabilitation on disease specific criteria.

5. The Delphi survey has been justified as ‘a direct response to Stakeholders’ comments on the initial consultation draft that the guidance did not present a complete stroke rehabilitation pathway…’. However this was because of the scope of the guidelines and the exclusion of high quality evidence. It would have been preferable to re visit these aspects than embark on this Delphi survey.

6. It is not the size but the representativeness of the expert sample which is in question. Other groups may have identified and suggested experts but the sampling frame was under the control of NICE. We cannot see how one could conclude, given the small numbers of particular groups of individuals involved, that there was ‘no evidence that the responses were systematically different to each other.’

7. There may be no ‘hard and fast rules’ about reaching consensus but there is relevant literature (for example, 1, 2); the methodology used in this guideline was flawed and the questions posed were simply wrong.

8. We do not accept that the recommendations ‘reflect the evidence available’. Moreover we do not think that the criticism from stakeholders regarding ‘taking a more holistic approach’ related to the formulation of the recommendations.

9. We are interested in the comment that skilled clinicians could use their judgment. This seems to fly in the face of the usual stand by NICE on rigour and evidence.

10. We re-iterate that these research topics are not likely to be the most pressing in stroke rehabilitation.

11. We do not accept that this document ‘provides guidance to improve clinical care and inform patients and their carers and reduce variations in practice’

Yours faithfully,

Professor Avril Drummond, Professor of Healthcare Research, University of Nottingham.
Professor Marion Walker, Professor of Stroke Rehabilitation, University of Nottingham.
Professor Derick Wade, Consultant in Rehabilitation Medicine, The Oxford Centre for Enablement.
Professor Pippa Tyrrell, Professor of Stroke Medicine, University of Manchester.
Professor Nadina Lincoln, Professor of Clinical Psychology, University of Nottingham.
Professor Peter Langhorne, Professor of Stroke Care, University of Glasgow.
Professor Peter Sandercock, Professor of Medical Neurology, University of Edinburgh.

1. Murphy E, Black N, Lamping D, McKee C, Sanderson C, et al. Consensus development methods, and their use in clinical guideline development: a review. Health Technol Assess 1998;2(3).
2. Hsu C , Sandford B. The Delphi Technique: making Sense of Consensus. Practical Assessment, Research and Evaluation. 2007; 12: 10

Competing interests: AD, DW, PT and PL are members of the RCP Intercollegiate Stroke Working party. AD Member of NICE Stroke Rehabilitation GDG - resigned 2012. MW Associate Director for Rehabilitation, UK Stroke Research Network. MW Co-author European Stroke Rehabilitation Guidelines. DW Clinical Advisor to NICE MS Guideline Group. PL Co-ordinating Editor Cochrane Stroke Group. PS Member Cochrane Stroke Editorial Board

06 July 2013
Avril Drummond
Professor of Healthcare Research
Marion Walker, Derick Wade, Pippa Tyrrell, Nadina Lincoln, Peter Langhorne, Peter Sandercock
University of Nottingham
Faculty of Medicine and Health Sciences, University of Nottingham, A Floor, Queen's Medical Centre (QMC), Nottingham NG7 2HA