Major cerebral vessel occlusion in SLE due to circulating anticardiolipin antibodies.

The finding by Kalra et al that the physiotherapists in the stroke unit placed significantly greater emphasis on activities that addressed the specific functional needs of individual patients strongly suggests that an important difference in physiotherapy practices existed in the two treatment areas. The presence of significant differences between the two physiotherapy staffs could therefore explain (at least partly) the better outcome observed in the stroke unit. Relevant information about the physiotherapy staff involved in each arm of the study would therefore be welcome, as it would enable further analysis of the interesting results of this trial. Reference 1. Kalra L, Dale P, Crome P. Improving stroke rehabilitation: a controlled study. Response Our study 1 unequivocally showed that the outcome of stroke management was significantly better in stroke rehabilitation units compared with general wards. As discussed at length in the article, this difference was primarily due to better organization of services and targeting of therapy resources according to the ability and, more importantly, the needs of the patient rather than due to increased resource input in the stroke unit. We confirm that the therapists involved in both arms of the study were of equivalent grades (Senior Grade I) and that they were equally supported by physiotherapy and occupational therapy aids. None of the therapists involved in the study had formal specialist training in stroke management. The stroke unit was developed in a general medical ward using therapists already working on the ward rather than those specially recruited for their neurological interest. We believe that the role of factors such as the time spent by physiotherapists with stroke patients, the grade of the therapists, and specialist training in stroke management (as mentioned by Dr Panayiotou and Ms Beeson) have received too much emphasis in the past, with little attention being paid to what the therapy actually achieves and its relevance to the patients' needs. The major point made by our article was that this emphasis was misplaced: the efficiency of stroke units depends upon directing therapy toward adapting the patients' residual abilities to their future needs. The role of nontargeted but prescribed remedial treatment often seen in general wards and some stroke units may be "professionally appropriate" (especially in the British setting), but it is inefficient and of little benefit to patients. 2 We would agree with Dr Panayiotou and Ms Beeson that a responsive management philosophy contributed to the difference …