COMMENTARY ON: THE EFFECT OF A COMPREHENSIVE eREHABILITATION INTERVENTION ALONGSIDE CONVENTIONAL STROKE REHABILITATION ON DISABILITY AND HEALTHRELATED QUALITY OF LIFE: A PRE–POST COMPARISON

We applaud the study by Brouns et al., 2021 (1), eval­ uating the effects of a comprehensive e­rehabilitation intervention, alongside conventional stroke rehabili­ tation, on disability and health­related quality of life. However, we would like to draw the attention of the authors to a few concerns. The authors intended to assess “health­related quality of life”, as stated in the introduction. But, in the objective of the study, the term “quality of life” is used. This is confusing, as “quality of life” and “health­related qual­ ity of life” are different; the latter being more specific to patients’ health conditions. The authors should have specified if they were assessing generalized quality of life, health­related quality of life, or both (2). For the majority of aspects, including the study ap­ proval and the recruitment of patients, the authors refer to a Stroke Cohort Outcomes of Rehabilitation (SCORE) study. However, the SCORE study, as mentioned, was an observational study, and in the current study the authors explored the effects of interventions. Hence, as per the ethics guidelines for medical research, the experimental study should have been approved by the ethics committee and the trial registered with the clinical trial registering authority of the country (3). In the inclusion criteria, the authors mentioned an extremely broad range of patient’s ages, but have not reported the sex of patients, type of stroke, and localization of stroke, although they have mentioned these in the results. They should have specified their inclusion criteria using these factors, as these are all major predictors of stroke recovery. The type of stroke plays a crucial role in patient care, as older patients with ischaemic stroke have worse outcomes, both in terms of mortality and disability (4). In addition, the authors did not mention whether consent to participa­ tion was obtained from the patients. In the outcome measures, the Hospital Anxiety and Depression scale (HADS) and the Fatigue Severity Scale (FSS) were used to assess anxiety and depression, and fatigue, respectively, but the authors do not mention these factors in the selection criteria. These 2 factors are the most important ones to include in the study, as patients with post­stroke fatigue tend to have less energy than their pre­morbid levels. Patients feel tired all the time and require frequent rest periods during daily activities (5). Social restrictions and lack of meaningful activities lead to depression and, consequently, an additional deterioration in health­related quality of life (6). In the selection crite­ ria, the authors state that patients were excluded if they were unable to communicate in Dutch, but the outcomes, including Stroke Impact Scale (SIS) and FSS, reported by the authors were in English. It was not specified if the included patients had an understanding of English. The calculated sample size and number of patients included in the study are different, and the number of participants in the control and experimental group was not the same. This would have been a greater predictor of bias in the results. The Consolidated Standards of Reporting Trials (CONSORT) chart is not clearly defined. In the treatment, the authors included exercises to im­ prove physical and cognitive functions, but they did not include assessments of balance, coordination, mobility, stability, speech or aerobic capacity in addition to the assessment of cognitive functions. As this was a pre–post study, assessment of all these is essential to measure any significant improvement after the treatment. The authors also intended to provide rehabilitation for disability; however, they did not assess disability.