Intended for healthcare professionals

Rapid response to:

Practice Guidelines

Rehabilitation of patients with stroke: summary of SIGN guidance

BMJ 2010; 340 doi: (Published 15 June 2010) Cite this as: BMJ 2010;340:c2845

Rapid Response:

Rehabilitation of patients with stroke: summary of NICE guidance ignores powered wheelchair provision

The review by Smith et al [1] correctly emphasises the value of
rehabilitation following stroke, specifically in noting that recovery may
continue for many years after stroke. It makes no mention, however, of the
value of wheelchairs in overcoming problematic immobility, specifically
the growing literature on the value of powered wheelchairs, which have
been available for indoor/outdoor use in the UK since 1996 [2]. Although
eligibility criteria are stringent, several series (all of which have
included wheelchair users [hereafter referred to as users] with
cerebrovascular disease) have reported the value of electric powered
indoor/outdoor wheelchairs (EPIOCs) for users of all ages [3-6[, and their
carers [3;7].

A recent audit from Stanmore Specialist Wheelchair Service (since
disbanded) showed that of 554 current EPIOC users, 32 (6%) had a
diagnosis of cerebrovascular disease resulting in the need for a
wheelchair [8]. Users consisted of 20 men mean age 61 (range 38-78, sd 10)
years and 22 women age 56 (range 28-76 sd 13) years. A further 10 users
had cerebrovascular disease as a disabling comorbidity, presenting
primarily with spinal cord injury, (3), multiple sclerosis (2), lower limb
amputation (2) and miscellaneous diagnoses (3). Users were referred from
10 PCTs in North West London, and the distribution of referrals is shown
in the table.

It is clear that referrals were of younger patients with cerebrovascular
disease (CVD), sometimes with pre-existing disabling conditions.
Considering the high prevalence of post-stroke impairments leading to
disability, referral rates appeared very low – none for stroke in one PCT!
There are many potential explanations for the lack of referral for EPIOCs.
Cost constraints may be one factor, but it is more likely, in my opinion,
that these PCTs have no appropriate late rehabilitation for stroke
patients. Many stroke rehabilitation services appear to conclude when
patients are judged safe to live at home with likely little further
benefit from therapy. Only a few aim to increase participation in the
community [9] through good outdoor mobility. For those with a job, the
EPIOC costs can be shared with the Department for Work and Pensions [10]
through the Access to Work Scheme [11].

Late community rehabilitation after stroke should include
consideration of EPIOC provision.

Andrew Frank

Reference List

(1) Smith LN, James R, Barber M, Ramsay S, Gillespie D, Chung C et
al. Rehabilitation of patients with stroke: summary of SIGN guidance. BMJ
2010; 340(19th June):1356-1359.

(2) Department of Health. Powered indoor/outdoor wheelchairs for
severely disabled people. NHS Executive Health Service Guidelines
HSG(96)34[May 1996]. London: Department. of Health, 1996

(3) Frank AO, Ward JH, Orwell NJ, McCullagh C, Belcher M.
Introduction of the new NHS Electric Powered Indoor/outdoor Chair (EPIOC)
service: benefits, risks and implications for prescribers. Clin Rehabil
2000; 14(December):665-673.

(4) Evans S, Frank A, Neophytou C, De Souza LH. Older adults' use
of, and satisfaction with, electric powered indoor /outdoor wheelchairs.
Age and ageing 2007; 36(4):431-435.

(5) Davies A, De Souza LH, Frank AO. Changes in the quality of life
in severely disabled people following provision of powered indoor/outdoor
chairs. Disability and Rehabilitation 2003; 25(6):286-290.

(6) May M, Rugg S. Electrically powered indoor/outdoor wheelchairs:
recipients views of their effects on occupational performance and quality
of life. Br J Occup Ther 2010; 73(1):2-12.

(7) Frank AO, Neophytou C, Frank J, De Souza LH. Electric Powered
Indoor/outdoor Wheelchairs (EPIOCs): users views of influence on family,
friends and carers. Disabil Rehabil. In press 2010.

(8) Frank AO. Who uses Electric Powered Indoor/outdoor wheelchairs
(EPIOCS) in the UK National Health Service? retrospective review of 544
users. Proceedings of the 4th International Interdisciplinary Conference
on Posture and Powered Mobility. Exeter: Posture & Mobility Group,

(9) World Health Organization: report by the secretariat. The
International Classification of functioning, disability and health (ICIDH-
2). Geneva: World Health Organisation, 2002

(10) Frank AO, Ellis K, Yates M. Use of the voucher scheme for
provision of Electric Powered Indoor/outdoor Wheelchairs (EPIOCs). Posture
& Mobility 2008; 23(1):17-26.

(11) Department for Work & Pensions. Access to Work. 2009.
London, Department for Work and Pensions.
(accessed 22nd June 2010)

Competing interests:
None declared

Table showing presentation type with PCT

PCT   Presenting
        with CVD    Other
PCT 1	5	0	5
PCT 2	3	2	5
PCT 3	0	2	2
PCT 4	3	0	3
PCT 5	2	0	2
PCT 6	6	1	7
PCT 7	2	2	4
PCT 8	2	0	2
PCT 9	8	1	9
Pct 10	1	2	3
TOTAL	32	10	42

Competing interests: PCT Presenting with CVD Other presentations TOTALPCT 1 5 0 5PCT 2 3 2 5PCT 3 0 2 2PCT 4 3 0 3PCT 5 2 0 2PCT 6 6 1 7PCT 7 2 2 4PCT 8 2 0 2PCT 9 8 1 9Pct 10 1 2 3TOTAL 32 10 42

22 June 2010
Andrew O. Frank
School of Health Science and Social Care, Brunel University, UB8 3PH