Beyond the RCT - understanding the relationship between interventions, individuals and outcome - the example of neurological rehabilitation.
BACKGROUND
Rehabilitation is highly complex, involving multiple processes, outcomes and stakeholders. The way we deliver our services and work with our clients and their families should be informed by research approaches that produce the wide range of knowledge needed. This article aims to explore the degree to which the dominant approach to 'evidence' (the randomised clinical trial or RCT) meets those needs and discuss alternate/additional ways of gaining evidence.


METHODS
A critical review of the literature allowing exploration of problems encountered in rehabilitation RCTs and alterative approaches.


RESULTS
We discuss some problematic issues related to using RCTs in rehabilitation research (for example the large number of people excluded from trials, and the small numbers of people with some neurological conditions making RCTs non-viable). Alternative approaches are discussed including clinical practice improvement studies (sometimes called practice-based evidence or PBE), which provide data on patients treated in routine practice; qualitative research, which can provide an understanding of the users of health care services to ensure they are meeting their needs; and metasynthesis, which can be used to summarise several qualitative studies to enhance our understanding of the principles underlying service delivery. Finally, we explore how clinicians and commissioners often use evidence generated by forms of research other than the RCT.


CONCLUSIONS
The best answers about how to enhance rehabilitation outcomes are likely to come from a combination and integration of the most appropriate methods. In conclusion, we urge for more joined up thinking, for learning from different fields so that we can develop more effective and appropriate health care and rehabilitation.
Kersten
Paula
P
School of Health Sciences, University of Southampton, Southampton SO17 1BJ, United Kingdom. P.Kersten@soton.ac.uk
Ellis-Hill
Caroline
C
McPherson
Kathryn M
KM
Harrington
Rachel
R
D006801:Humans; D015201:Meta-Analysis as Topic; D009422:Nervous System Diseases / Q000534:rehabilitation; D017063:Outcome Assessment, Health Care; D036301:Qualitative Research; D016032:Randomized Controlled Trials as Topic; D012107:Research Design