No Early Mobilization After Stroke: Lessons Learned from the AVERT Trial

Differential Effects of Time to Initiation of Therapy on Disability and Quality of Life in Patients With Mild and Moderate to Severe Ischemic Stroke

OBJECTIVE

To assess the effect of time to acute therapy on health-related quality of life (HRQoL) and disability after ischemic stroke.

DESIGN

Prospective cohort study.

SETTING

Comprehensive stroke care center in a large metropolitan city.

PARTICIPANTS

Patients (N=553; mean age, 67 y; 51.9% male; 64.4% white; 88.8% ischemic stroke) with ischemic stroke or transient ischemic attack (TIA) enrolled in a longitudinal observational study between August 2012 to January 2014 who received rehabilitation services.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Disability status was assessed with the modified Rankin Scale (mRS) and Barthel Index (BI). HRQoL was assessed using the Quality of Life in Neurological Disorders measures of executive function, general cognitive concerns, upper extremity dexterity, and lower extremity mobility. Time to therapy consult and treatment were defined as the number of days from hospital admission to initial consult by a therapist and number of days from hospital admission to initial treatment, respectively.

RESULTS

Among the participants, the median number of days from hospital admission to acute therapy consult was 2 days (interquartile range, 1-3d). Multivariable linear and logistic regression models indicated that for those with the National Institutes of Health Stroke Scale (NIHSS) score<5, longer time to therapy consult was associated with worse BI scores (BI=100; odds ratio [OR], 0.818; P=.008), executive function T scores (b=-0.865; P=.001), and general cognitive concerns T scores (b=-0.609; P=.009) at 1-month in adjusted analyses. In those with NIHSS score≥5, longer time to therapy treatment led to increased disability (ie, mRS≥ 2; OR, 1.15; P=.039) and lower extremity mobility T scores (b=-0.591; P=.046) at 1 month in adjusted analyses.

CONCLUSIONS

Longer time to initiation of acute therapy has differential effects on poststroke disability and HRQoL up to 1-month after ischemic stroke and TIA. The effect of acute therapy consult is more notable for those with mild deficits, while the effect of acute therapy treatment is more notable for those with moderate to severe deficits. Minimizing time to therapy consults and treatments in the acute hospital period might improve outcomes after ischemic stroke and TIA.

Longer Time Before Acute Rehabilitation Therapy Worsens Disability After Intracerebral Hemorrhage

OBJECTIVE

Assess the association of time to initiation of acute rehabilitation therapy with disability after intracerebral hemorrhage (ICH) and identify predictors of time to initiation of rehabilitation therapy.

DESIGN

Retrospective data analysis of prospectively collected data from an ongoing observational cohort study.

SETTING

Large comprehensive stroke center in a metropolitan area.

PARTICIPANTS

Adults with ICH consecutively admitted (n=203).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Disability was assessed with the modified Rankin Scale (mRS), with poor outcome defined as mRS 4-6 (dependence or worse). Time to initiation of acute rehabilitation therapy was defined as the number of days between hospital admission and the first consult by any rehabilitation therapy specialist (eg, physical therapy, occupational therapy, speech therapy).

RESULTS

The median number of days from hospital admission to initiation of acute rehabilitation therapy was 3 (range=2-7). Multivariable logistic regression models indicated that each additional day between admission and initiation of acute rehabilitation therapy was associated with increased odds of poor outcome at 30 days (adjusted odds ratio [OR]=1.151; 95% confidence interval [CI]=1.044-1.268; P=.005) and at 90 days (adjusted OR=1.107; 95% CI=1.003-1.222; P=.044) for patients with ICH. A multivariable linear regression model used to identify the predictors of time to initiation of rehabilitation therapy identified heavy drinking (>5 drinks per day), premorbid mRS<4, presence of pulmonary embolism, and longer length of stay in the intensive care unit as independent predictors of later initiation of acute rehabilitation therapy.

CONCLUSIONS

Longer time to initiation of acute rehabilitation therapy after ICH may have persistent effects on poststroke disability. Delays in acute rehabilitation therapy consults should be minimized and may improve outcomes after ICH.

Reduced tonic inhibition after stroke promotes motor performance and epileptic seizures

Stroke survivors often recover from motor deficits, either spontaneously or with the support of rehabilitative training. Since tonic GABAergic inhibition controls network excitability, it may be involved in recovery. Middle cerebral artery occlusion in rodents reduces tonic GABAergic inhibition in the structurally intact motor cortex (M1). Transcript and protein abundance of the extrasynaptic GABAA-receptor complex α4β3δ are concurrently reduced (δ-GABAARs). In vivo and in vitro analyses show that stroke-induced glutamate release activates NMDA receptors, thereby reducing KCC2 transporters and down-regulates δ-GABAARs. Functionally, this is associated with improved motor performance on the RotaRod, a test in which mice are forced to move in a similar manner to rehabilitative training sessions. As an adverse side effect, decreased tonic inhibition facilitates post-stroke epileptic seizures. Our data imply that early and sometimes surprisingly fast recovery following stroke is supported by homeostatic, endogenous plasticity of extrasynaptic GABAA receptors.