In Reply Ms Peters and Dr Page raise several important and timely issues confronting the clinical rehabilitation community. Approximately 30% of stroke survivors receive outpatient rehabilitation, far fewer than those who report residual disability 6 months after stroke1 and less than expected if clinical practice guideline recommendations were followed.2 Although considerable resources are devoted to stroke rehabilitation and aftercare, few rigorous phase 3 randomized clinical trials have been reported; therefore, it is relatively uncharted territory. A recent Cochrane overview of interventions for improving upper limb function found no evidence to support the effectiveness of routine practices and concluded that evidence pertaining to dose is lacking.3 ICARE is 1 of 5 recent phase 3 randomized clinical trials in rehabilitation that did not find the hypothesized superiority of an investigational intervention relative to an appropriate control.4,5 The messages from these 5 trials are clear: (1) equivalence among investigational and control interventions suggests to practicing clinicians that more than 1 intervention has efficacy for a particular motor outcome (eg, walking speed, arm motor function); (2) the mechanism underlying investigational rehabilitation interventions is poorly understood; and (3) the primary outcomes may be less than optimally sensitive or limited in scope.
Winstein C, Wolf S, Dromerick AW. Task-Oriented Rehabilitation Program for Stroke—Reply. JAMA. 2016;316(1):102. doi:10.1001/jama.2016.5025