Post-Stroke Rehabilitation, vol. 16, A Clinical Practice Guideline.

Gresham GE, Duncan PW, Stason WB, et al. Rockville, MD 20852, US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1 995, paperback, 248 pp, $1 0.

The goal of this book was to "improve the effectiveness of stroke rehabilitation by identifying the most effective methods of assessing and treating people who have disabilities due to stroke." The degree to which the book's goal is realized is remarkable, considering the thousands of articles that have been published on the topic and the diversity of views. A panel of 19 was involved in developing the guideline, and more than 50 peer reviewers participated.

The book begins with an executive summary and overview. The rest of the book is organized into six chapters: "Epidemiology and Natural History of Stroke," "Assessment Methods for Patients With Stroke," "Rehabilitation During Acute Care for Stroke," "Screening for Rehabilitation and Choice of Setting," "Managing Rehabilitation," and "Transition to the Community." Placed strategically throughout the text are over 60 recommendations that include an appraisal of the weight of underlying research evidence and expert opinion. Twenty-eight tables provide an excellent summary of information relevant to various topics. For example, Table 15 summarizes six studies that provide "Evidence on the Effectiveness of Different Types of Physical Therapy." Thirteen recommended standardized assessment instruments are presented as attachments at the end of the book. Each attachment names the instrument; provides a description; cites evidence for validity, reliability, and sensitivity; describes uses and time to administer; and lists strengths and weaknesses.

The information provided is extensive. Aside from a few notable exceptions, the information has a clear basis in the extant research literature that will encourage clinicians to reexamine traditional assessment and treatment procedures. There are no nostrums in the Guideline.

The aforementioned notwithstanding, the Guideline is not sufficient to direct clinical practice. Some literature of considerable importance is not covered, including recent research on acupuncture and the use of the treadmill and weight unloading for gait training. Many specific tests with clinical worth are not mentioned at all, and the relative value or need for different assessment options is not always addressed.

Some of the conclusions presented in this book could dissuade clinicians from using potentially fruitful interventions. The book, for example, concludes that a study by Inaba et al showed "no significant differences among groups at two months." Although true, the statement disregards the finding that at 1 month, more patients in a resistance training group (64%) made a significant improvement in activities of daily living than did patients in a control group (38%) or an active exercise group (30%). Considering the abbreviated lengths of stay for patients with stroke, the results at 1 month reported by Inaba et al may have substantial implications.

This book contains a great deal of valuable information for therapists participating in the rehabilitation of patients with stroke. It is, as intended, a useful guide for practice; however, it should be supplemented with other literature. Inasmuch as a therapist's practice is in line with the guidelines, the book may serve as justification for the therapist's choice of assessments and treatments.

Richard W Bohannon, EdD, PT, NCS Univ of Connecticut Storrs, Conn

Dr Bohannon is Professor in the Physical Therapy Program at The University of Connecticut. He is also the author of over 50 papers relevant to stroke and rehabilitation and an editorial board member of several journals concerned with stroke rehabilitation.