Early Mobilisation after Stroke: Review of the Literature

Activation of BDNF- and VEGF-mediated Neuroprotection by Treadmill Exercise Training in Experimental Stroke

Early treatment of ischemic stroke is one of the most effective ways to reduce brains' cell death and promote functional recovery. This study was designed to examine the effect of aerobic exercise on post ischemia/reperfusion injury on concentration and expression of brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF) after inducing a neuronal loss in CA1 region of hippocampus in Male Wistar rats. Three experimental groups including sham(S), ischemia/reperfusion-control (IRC) and ischemia/reperfusion exercise (IRE) were used for this purpose. The rats in the IRE group received a bilateral carotid artery occlusion treatment. They ran for 45 minutes on a treadmill five days per week for eight consecutive weeks. Cresyl violet (Nissl), Hematoxylin (H & E) and Eosin staining procedure were used to determine the extent of damage. A ladder rung walking task was used to assess the functional impairments and recovery after the ischemic lesion. ELISA and immunohistochemistry method were employed to measure BDNF and VEGF protein expressions. The result showed that the brain ischemia/reperfusion condition increased the cell death in hippocampal CA1 neurons and impaired motor performance on the ladder rung task whereas the aerobic exercise program significantly decreased the brain cell's death and improved motor skill performance. It was concluded that ischemic brain lesion decreased the BDNF and VEGF expression. It seems that the aerobic exercise following the ischemia/reperfusion potentially promotes neuroprotective mechanisms and neuronal repair and survival mediated partly by BDNF and other pathways.

Can Early Neuromuscular Rehabilitation Protocol Improve Disability after a Hemiparetic Stroke? A Pilot Study

Background: The impairment of limb function and disability are among the most important consequences of stroke. To date, however, little research has been done on the early rehabilitation trial (ERT) after stroke in these patients. The purpose of this study was to evaluate the impact of ERT neuromuscular protocol on motor function soon after hemiparetic stroke. The sample included twelve hemiparetic patients (54.3 ± 15.4 years old) with ischemic stroke (n = 7 control, n = 5 intervention patients). ERT was started as early as possible after stroke and included passive range of motion exercises, resistance training, assisted standing up, and active exercises of the healthy side of the body, in addition to encouraging voluntary contraction of affected limbs as much as possible. The rehabilitation was progressive and took 3 months, 6 days per week, 2–3 hours per session. Fugle-Meyer Assessment (FMA), Box and Blocks test (BBT) and Timed up and go (TUG) assessments were conducted. There was a significantly greater improvement in the intervention group compared to control: FMA lower limbs (p = 0.001), total motor function (p = 0.002), but no significant difference in FMA upper limb between groups (p = 0.51). The analysis of data related to BBT showed no significant differences between the experimental and control groups (p = 0.3). However, TUG test showed significant differences between the experimental and control groups (p = 0.004). The most important finding of this study was to spend enough time in training sessions and provide adequate rest time for each person. Our results showed that ERT was associated with improved motor function but not with the upper limbs. This provides a basis for a definitive trial.

Impact of Early Rehabilitation on Outcomes in Patients With Acute Ischemic Stroke After Endovascular Treatment

Background

This study aims to examine the effects of early rehabilitation on functional outcomes in patients with acute ischemic stroke treated with endovascular treatment (EVT).

Methods

Eligible patients with large vessel occlusion stroke treated with EVT, who received early rehabilitation or standard care treatment during hospitalization, were enrolled in a multicenter registration, prospective observational study, a registration study for Critical Care of Acute Ischemic Stroke After Recanalization. Early rehabilitation was defined as rehabilitation interventions initiated within 1 week after acute stroke. The primary outcome was the favorable functional outcome (defined as modified Rankin Scale scores of 0 to 2) at 90 days. Independent association between early rehabilitation and the primary outcome was investigated using multivariable logistic regression in the entire sample and in subgroups.

Results

A total of 1,126 patients (enrolled from July 2018 to May 2019) were included in the analyses, 273 (24.2%) in the early rehabilitation group and 853 (75.8%) in the standard care group. There was no significant difference in favorable functional outcomes at 90 days between the two groups (45.4 vs. 42.6%, p = 0.41). Patients in the early rehabilitation group had a lower death rate within 90 days compared with the standard care group (6.2 vs. 20.5%, p < 0.01). The multivariable logistic regression analyses showed that the early rehabilitation was not significantly associated with the favorable functional outcome at 90 days (adjusted odds ratio, 1.01 [95% CI, 0.70–1.47]; p = 0.95). There was no significant difference between subgroups in the favorable functional outcome at 90 days. No significant interaction was found between subgroups.

Conclusions

Patients with stroke receiving early rehabilitation had a lower death rate. However, these clinically meaningful effects of early rehabilitation did not show on functional outcome at 90 days in patients with large vessel occlusion stroke treated with EVT.

Registration

URL: http://www.chictr.org.cn; Unique identifier: ChiCTR1900022154.

Plantar Pressure and Contact Area Measurement of Foot Abnormalities in Stroke Rehabilitation

BACKGROUND

Evaluation of plantar pressure in stroke patients is a parameter that could be used for monitoring and comparing how the timing of starting a rehabilitation program effects patient improvement.

METHODS

We performed the following clinical and functional evaluations: initial moment (T1), intermediate (T2), and final evaluation at one year (T3). At T1 we studied 100 stroke patients in two groups, A and B (each 50 patients). The first group, A, started rehabilitation in the first three months after having a stroke, and group B started after three months from the time of stroke. Due to the impediments observed during rehabilitation, we made biomechanic evaluation for two lots, I and II (each 25 patients). Assessment of the patient was carried out by clinical (neurologic examination), functional (using the Tinetti Functional Gait Assessment Test for classifying the gait), and biomechanical evaluation (maximal plantar pressure (Pmax), contact area (CA), and pressure distribution (COP)).

RESULTS

The Tinetti scale for gait had the following scores: for group A, from 1.34 at the initial moment (T1) to 10.64 at final evaluation (T3), and for group B, 3.08 at initial moment (T1) to 9 at final evaluation (T3). Distribution of COP in the left hemiparesis was uneven at T1 but evolved after rehabilitation. The right hemiparesis had uniform COP distribution even at T1, explained by motor dominance on the right side. CA and Pmax for lot I increased more than 100%, meaning that there is a possibility for favorable improvement if the patients start the rehabilitation program in the first three months after stroke. For lot II, increases of the parameters were less than lot I.

DISCUSSIONS

The recovery potential is higher for patients with right hemiparesis. Biomechanic evaluation showed diversity regarding compensatory mechanisms for the paretic and nonparetic lower limb.

CONCLUSIONS

CA and Pmax are relevant assessments for evaluating the effects on timing of starting a rehabilitation program after a stroke.

Very early versus delayed mobilisation after stroke

BACKGROUND

Very early mobilisation (VEM) is performed in some stroke units and recommended in some acute stroke clinical guidelines. However, it is unclear whether very early mobilisation independently improves outcome after stroke.

OBJECTIVES

To determine whether very early mobilisation (started as soon as possible, and no later than 48 hours after onset of symptoms) in people with acute stroke improves recovery (primarily the proportion of independent survivors) compared with usual care.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched 31 July 2017). We also systematically searched 19 electronic databases including; CENTRAL; 2017, Issue 7 in the Cochrane Library (searched July 2017), MEDLINE Ovid (1950 to August 2017), Embase Ovid (1980 to August 2017), CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to August 2017) , PsycINFO Ovid (1806 to August 2017), AMED Ovid (Allied and Complementary Medicine Database), SPORTDiscus EBSCO (1830 to August 2017). We searched relevant ongoing trials and research registers (searched December 2016), the Chinese medical database, Wanfangdata (searched to November 2016), and reference lists, and contacted researchers in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of people with acute stroke, comparing an intervention group that started out-of-bed mobilisation within 48 hours of stroke, and aimed to reduce time-to-first mobilisation, with or without an increase in the amount or frequency (or both) of mobilisation activities, with usual care, where time-to-first mobilisation was commenced later.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, assessed risk of bias, and applied the GRADE approach to assess the quality of the evidence. The primary outcome was death or poor outcome (dependency or institutionalisation) at the end of scheduled follow-up. Secondary outcomes included death, dependency, institutionalisation, activities of daily living (ADL), extended ADL, quality of life, walking ability, complications (e.g. deep vein thrombosis), patient mood, and length of hospital stay. We also analysed outcomes at three-month follow-up.

MAIN RESULTS

We included nine RCTs with 2958 participants; one trial provided most of the information (2104 participants). The median (range) delay to starting mobilisation after stroke onset was 18.5 (13.1 to 43) hours in the VEM group and 33.3 (22.5 to 71.5) hours in the usual care group. The median difference within trials was 12.7 (4 to 45.6) hours. Other differences in intervention varied between trials; in five trials, the VEM group were also reported to have received more time in therapy, or more mobilisation activity.Primary outcome data were available for 2542 of 2618 (97.1%) participants randomized and followed up for a median of three months. VEM probably led to similar or slightly more deaths and participants who had a poor outcome, compared with delayed mobilisation (51% versus 49%; odds ratio (OR) 1.08, 95% confidence interval (CI) 0.92 to 1.26; P = 0.36; 8 trials; moderate-quality evidence). Death occurred in 7% of participants who received delayed mobilisation, and 8.5% of participants who received VEM (OR 1.27, 95% CI 0.95 to 1.70; P = 0.11; 8 trials, 2570 participants; moderate-quality evidence), and the effects on experiencing any complication were unclear (OR 0.88; 95% CI 0.73 to 1.06; P = 0.18; 7 trials, 2778 participants; low-quality evidence). Analysis using outcomes collected only at three-month follow-up did not alter the conclusions.The mean ADL score (measured at end of follow-up, with the 20-point Barthel Index) was higher in those who received VEM compared with the usual care group (mean difference (MD) 1.94, 95% CI 0.75 to 3.13, P = 0.001; 8 trials, 9 comparisons, 2630/2904 participants (90.6%); low-quality evidence), but there was substantial heterogeneity (93%). Effect sizes were smaller for outcomes collected at three-month follow-up, rather than later.The mean length of stay was shorter in those who received VEM compared with the usual care group (MD -1.44, 95% CI -2.28 to -0.60, P = 0.0008; 8 trials, 2532/2618 participants (96.7%); low-quality evidence). Confidence in the answer was limited by the variable definitions of length of stay. The other secondary outcome analyses (institutionalisation, extended activities of daily living, quality of life, walking ability, patient mood) were limited by lack of data.Sensitivity analyses by trial quality: none of the outcome conclusions were altered if we restricted analyses to trials with the lowest risk of bias (based on method of randomization, allocation concealment, completeness of follow-up, and blinding of final assessment), or information about the amount of mobilisation.Sensitivity analysis by intervention characteristics: analyses restricted to trials where the mean VEM time-to-first mobilisation was less than 24 hours, showed an odds of death of 1.35 (95% CI 0.99 to 1.83; P = 0.06; I² = 25%; 5 trials). Analyses restricted to the trials that clearly reported a more prolonged out-of-bed activity showed a similar primary outcome (OR 1.14; 0.96 to 1.35; P = 0.13; I² = 28%; 5 trials), and odds of death (OR 1.27; 0.93 to 1.73; P = 0.13; I² = 0%; 4 trials) to the main analysis.Exploratory network meta-analysis (NMA): we were unable to analyze by the amount of therapy, but low-quality evidence indicated that time-to-first mobilisation at around 24 hours was associated with the lowest odds of death or poor outcome, compared with earlier or later mobilisation.

AUTHORS' CONCLUSIONS

VEM, which usually involved first mobilisation within 24 hours of stroke onset, did not increase the number of people who survived or made a good recovery after their stroke. VEM may have reduced the length of stay in hospital by about one day, but this was based on low-quality evidence. Based on the potential hazards reported in the single largest RCT, the sensitivity analysis of trials commencing mobilisation within 24 hours, and the NMA, there was concern that VEM commencing within 24 hours may carry an increased risk, at least in some people with stroke. Given the uncertainty around these effect estimates, more detailed research is still required.

The practice and predictors of early mobilization of patients post-acute admission to a specialized stroke center

BACKGROUND

Early mobilization (EM) post-stroke is recommended; however, the ideal timing and nature of EM, and factors that may influence EM practice are unclear.

OBJECTIVES

The primary objective was to describe the type and extent of mobilization 0-48 h post-stroke admission to acute hospital care. A secondary objective was to evaluate whether pre-stroke functional level, stroke severity, tissue plasminogen activator (tPA) administration, and level of consciousness (LOC) predicted any passive, any active, and out-of-bed mobilization (i.e. sitting at edge-of-bed, standing, or ambulation) 0-24 h post-admission.

METHODS

A quantitative, cross-sectional, retrospective review of health records of patients admitted to a specialized acute stroke center in 2016 was conducted.

RESULTS

Data from 296 eligible health records were abstracted. Median age was 73 years, and 87% of patients had sustained an ischemic stroke. Active, passive, and out-of-bed mobilization occurred in 91.6%, 57.1%, and 24.3% of patients by 12 h post-admission, respectively, and 99.3%, 78.4%, and 77.4% of patients by 48 h post-admission, respectively. Administration of tPA, stroke severity, and impaired LOC, were each associated with any passive mobilization, and no tPA administration, stroke severity, and normal LOC were each associated with out-of-bed mobilization 0-24 h post-admission (p < 0.05).

CONCLUSIONS

Almost all patients receive active mobilization by 12 h post-admission whereas out-of-bed mobilization is infrequent. In the first 24 h post-admission, clinicians may prioritize passive over out-of-bed mobilization when patients have received tPA, present with severe stroke, and have impaired LOC. This conservative approach is unsurprising given the lack of clear practice recommendations for these situations.

Physiological Effects of Early Incremental Mobilization of a Patient with Acute Intracerebral and Intraventricular Hemorrhage Requiring Dual External Ventricular Drainage

BACKGROUND

Recent trials have challenged the notion that very early mobility benefits patients with acute stroke. It is unclear how cerebral autoregulatory impairments, prevalent in this population, could be affected by mobilization. The safety of mobilizing patients who have external ventricular drainage (EVD) devices for cerebrospinal fluid diversion and intracranial pressure (ICP) monitoring is another concern due to risk of device dislodgment and potential elevation in ICP. We report hemodynamic and ICP responses during progressive, device-assisted mobility interventions performed in a critically ill patient with intracerebral hemorrhage (ICH) requiring two EVDs.

METHODS

A 55-year-old man was admitted to the Neuroscience Critical Care Unit with an acute thalamic ICH and complex intraventricular hemorrhage requiring placement of two EVDs. Progressive mobilization was achieved using mobility technology devices. Range of motion exercises were performed initially, progressing to supine cycle ergometry followed by incremental verticalization using a tilt table. Physiological parameters were recorded before and after the interventions.

RESULTS

All mobility interventions were completed without any adverse event or clinically detectable change in the patient's neurological state. Physiological parameters including hemodynamic variables and ICP remained within prescribed goals throughout.

CONCLUSION

Progressive, device-assisted early mobilization was feasible and safe in this critically ill patient with hemorrhagic stroke when titrated by an interdisciplinary team of skilled healthcare professionals. Studies are needed to gain insight into the hemodynamic and neurophysiological responses associated with early mobility in acute stroke to identify subsets of patients who are most likely to benefit from this intervention.

The influence of physiotherapy on motor control re-education among patients after ischemic stroke

Introduction: The authors present the influence of two physiotherapy programmes on the re-education of motor behaviour in patients after ischemic stroke. One of them is a programme based on exercises combining PNF and NTD Bobath elements, while the other is a deep trunk muscle exercises with the use of the PUM armchair. Material and methods: The study material was a group of 60 patients of both sexes who suffered ischemic stroke resulting in hemiparesis. They were divided into two groups. Group I consisted of 18 women (60%) and 12 men (40%) who followed the author’s programme of deep muscle activation exercises using the PUM armchair. Group II consisting of 15 women (50%) and 15 men (50%) followed the exercise programme using standard methods, i.e. based on PNF and Bobath methods. Results: They indicate the effectiveness of both methods, with the predominance of the author’s programme. Conclusion: The improvement of deep muscle activity in the examined group of patients has positive influence on their muscle tone, balance and postural control, which in turn, reduces muscle tension, improves gait stereotype and load characteristics of lower limbs. ischemic stroke, postural control, deep muscles Article received: 30.01.2018; Accepted: 30.03.2018

Impact of Rehabilitation on Outcomes in Patients With Ischemic Stroke

Background and Purpose—

We aimed to examine the concurrent effects of timing and intensity of rehabilitation on improving activities of daily living (ADL) among patients with ischemic stroke.

Methods—

Using the Japanese Diagnosis Procedure Combination inpatient database, we retrospectively analyzed consecutive patients with ischemic stroke at admission who received rehabilitation (n=100 719) from April 2012 to March 2014. Early rehabilitation was defined as that starting within 3 days after admission. The average rehabilitation intensity per day was calculated as the total units of rehabilitation during hospitalization divided by the length of hospital stay. A multivariable logistic regression analysis with multiple imputation and an instrumental variable analysis were performed to examine the association of early and intensive rehabilitation with the proportion of improved ADL score.

Results—

The proportion of improved ADL score was higher in the early and intensive rehabilitation group. The multivariable logistic regression analysis showed that significant improvements in ADL were observed for early rehabilitation (odds ratio: 1.08; 95% confidence interval: 1.04–1.13; P <0.01) and intensive rehabilitation of >5.0 U/d (odds ratio: 1.87; 95% confidence interval: 1.69–2.07; P <0.01). The instrumental variable analysis showed that an increased proportion of improved ADL was associated with early rehabilitation (risk difference: 2.8%; 95% confidence interval: 2.0–3.4%; P <0.001) and intensive rehabilitation (risk difference: 5.6%; 95% confidence interval: 4.6–6.6%; P <0.001).

Conclusions—

The present results suggested that early and intensive rehabilitation improved ADL during hospitalization in patients with ischemic stroke.

Effect of early mobilization and rehabilitation on complications in aneurysmal subarachnoid hemorrhage

OBJECTIVE

Early rehabilitation is effective in an array of acute neurological disorders but it is not established as part of treatment guidelines after aneurysmal subarachnoid hemorrhage (aSAH). This may in part be due to the fear of aggravating the development of cerebral vasospasm, which is the most feared complication of aSAH. The aim of this study was to evaluate the effect of early rehabilitation and mobilization on complications during the acute phase and within 90 days after aSAH.

METHODS

This was a prospective, interventional study that included patients with aSAH at the neuro-intermediate ward after aneurysm repair. The control group received standard treatment, whereas the early rehab group underwent early rehabilitation and mobilization in addition to standard treatment. Clinical and radiological characteristics of patients with aSAH, progression in mobilization, and treatment variables were registered. The frequency and severity of cerebral vasospasm, cerebral infarction acquired in conjunction with the aSAH, and acute and chronic hydrocephalus, as well as pulmonary and thromboembolic complications, were compared between the 2 groups.

RESULTS

Clinical and radiological characteristics of patients with aSAH were similar between the groups. The early rehab group was mobilized beginning on the first day after aneurysm repair. The significantly quicker and higher degree of mobilization in the early rehab group did not increase complications. Clinical cerebral vasospasm was not as frequent in the early rehab group and it also tended to be less severe. Each step of mobilization achieved during the first 4 days after aneurysm repair reduced the risk of severe vasospasm by 30%. Acute and chronic hydrocephalus were similar in both groups, but there was a tendency toward earlier shunt implantation among patients in the control group. Pulmonary infections, thromboembolic events, and death before discharge or within 90 days after the ictus were similar between the 2 groups.

CONCLUSIONS

Early rehabilitation of patients after aSAH is safe and feasible. The earlier and higher degree of mobilization does not increase neurosurgical complications. Rather, the frequency and severity of cerebral vasospasm following aSAH are alleviated and are not aggravated by early rehabilitation.

Clinical trial registration no.: NCT01656317 (www.clinicaltrials.gov).

Acute Ischemic Stroke: Current Status and Future Directions

The evolving knowledge on stroke in conjunction with advances in the field of imaging, treatment approaches using recombinant tissue plasminogen activator (rtPA) or thrombectomy devices in recanalization, and efficient emergency stroke workflow processes have opened new frontiers in managing patients with an acute ischemic stroke. These frontiers have been reformed and overcome in overcoming the decades-long watch and wait approach towards patients with ischemic stroke. In this article, we focus on the current strategies for managing ischemic stroke and conclude by providing a brief overview of anticipating developments that can transform future stroke treatments.

Heads Up! A Novel Provocative Maneuver to Guide Acute Ischemic Stroke Management

BACKGROUND

A common dilemma in acute ischemic stroke management is whether to pursue recanalization therapy in patients with large vessel occlusions but minimal neurologic deficits. We describe and report preliminary experience with a provocative maneuver, i.e. 90-degree elevation of the head of bed for 30 min, which stresses collaterals and facilitates decision-making.

METHODS

A prospective cohort study of <7.5 h of acute anterior circulation territory ischemia patients with minimal deficits despite middle cerebral artery (MCA) or internal carotid artery (ICA) occlusive disease.

RESULTS

Five patients met the study entry criteria. Their mean age was 78.4 years (range 65-93). All presented with substantial deficits (median NIHSS score 11, range 5-22), but improved while in supine position during initial imaging to normal or near-normal (NIHSS score 0-2). MRA showed persistent M1 MCA occlusions in 4, critical ICA stenosis or occlusion in 1, and substantial perfusion-diffusion mismatch in all. To evaluate the potential for eventual collateral failure, patients were placed in a head of bed upright posture. Mean arterial pressure and heart rate were unchanged. Two showed no neurologic worsening and were treated with supportive care with excellent final outcome. Three showed worsening, including recurrent hemiparesis and aphasia at the 6th, recurrent aphasia at the 23rd, and recurrent hemineglect at the 15th upright minute. These 3 underwent endovascular recanalization therapies with successful reperfusion and excellent final outcome.

CONCLUSION

The 'Heads Up' test may be a useful, simple maneuver to assess the risk of collateral failure and guide the decision to pursue recanalization therapy in acute cerebral ischemia patients with minimal deficits despite persisting large cerebral artery occlusion.

Exercise in the Early Stage after Stroke Enhances Hippocampal Brain-Derived Neurotrophic Factor Expression and Memory Function Recovery

BACKGROUND

Exercise in the early stage after stroke onset has been shown to facilitate the recovery from physical dysfunction. However, the mechanism of recovery has not been clarified. In this study, the effect of exercise on spatial memory function recovery in the early stage was shown, and the mechanism of recovery was discussed using a rat model of brain embolism.

METHODS

Intra-arterial microsphere (MS) injection induced small emboli in the rat brain. Treadmill exercise was started at 24 hours (early group) or 8 days (late group) after MS injection. The non-exercise (NE) and sham-operated groups were included as controls. Memory function was evaluated by the Morris water maze test, and hippocampal levels of brain-derived neurotrophic factor (BDNF) were measured by enzyme-linked immunosorbent assays. To further investigate the effect of BDNF on memory function, BDNF was continuously infused into the hippocampus via implantable osmotic pumps in the early or late stage after stroke.

RESULTS

Memory function significantly improved only in the early group compared with the late and the NE groups, although hippocampal BDNF concentrations were temporarily elevated after exercise in both the early and the late groups. Rats infused with BDNF in the early stage exhibited significant memory function recovery; however, rats that received BDNF infusion in the late stage showed no improvement.

CONCLUSION

Exercise elevates hippocampal BDNF levels in the early stage after cerebral embolism, and this event facilitates memory function recovery.

Functional Neuroimaging in Stroke Recovery and Neurorehabilitation: Conceptual Issues and Perspectives

Background

In stroke, functional neuroimaging has become a potent diagnostic tool; opened new insights into the pathophysiology of ischaemic damage in the human brain; and made possible the assessment of functional–structural relationships in postlesion recovery.

Summary of review

Here, we give a critical account on the potential and limitation of functional neuroimaging and discuss concepts related to the use of neuroimaging for exploring the neurobiological and neuroanatomical mechanisms of poststroke recovery and neurorehabilitation. We identify and provide evidence for five hypotheses that functional neuroimaging can provide new insights into: adaptation occurs at the level of functional brain systems; the brain–behaviour relationship varies with recovery and over time; functional neuroimaging can improve our ability to predict recovery and select individuals for rehabilitation; mechanisms of recovery reflect different pathophysiological phases; and brain adaptation may be modulated by experience and specific rehabilitation. The significance and application of this new evidence is discussed, and recommendations made for investigations in the field.

Conclusion

Functional neuroimaging is an important tool to explore the mechanisms underlying brain plasticity and, thereby, to guide clinical research in neurorehabilitation.

Stroke Rehabilitation 2007: What Should it Be?

Background

There are an estimated 62 million stroke survivors worldwide. The majority will have long-term disability. Despite this reality, there have been few large, high-quality randomized controlled trials of stroke rehabilitation interventions.

Summary of review

There is excellent evidence for the effectiveness of a number of stroke rehabilitation interventions, notably care of stroke patients in inpatient stroke units and stroke rehabilitation units providing organized, goal-focused care via a multidisciplinary team. Stroke units (in comparison with care on general medical wards) effectively reduce death and disability with the number needed to treat to prevent one person from failing to regain independence being 20. Unfortunately, only a minority of stroke patients have access to stroke unit care. The key principles of effective stroke rehabilitation have been identified. These include ( 1 ) a functional approach targeted at specific activities e.g. walking, activities of daily living, ( 2 ) frequent and intense practice, and ( 3 ) commencement in the first days or weeks after stroke.

Conclusion

The most effective approaches to restoration of brain function after stroke remain unknown and there is an urgent need for more high-quality research. In the meantime, simple, broadly applicable stroke rehabilitation interventions with proven efficacy, particularly stroke unit care, must be applied more widely.

[The early post-stroke mobilization]

Early mobilization is an important prerequisite for the successful recovery after stroke. However, it is unclear at present how early mobilization should be started after stroke. Three randomized controlled trials were devoted to the comparison of the effectiveness and safety of very early (within the first day after stroke) and early (within two days after stroke) mobilization. The meta-analysis of the results of these studies did not reveal any advantages of very early mobilization over early mobilization. One randomized control study was designed to compare the consequences of mobilization within 3 and 7 days after stroke. It has demonstrated that earlier mobilization is associated with fewer complications and does not exert negative effect on cerebral haemodynamics. A number of observational studies confirmed the positive effect of early mobilization on the outcome of stroke. It is concluded that it may be justified to start mobilization on the second day after stroke provided there are no contraindications to such modality. The practicability of very early mobilization remains to be elucidated.

Early mobilization in ischemic stroke: a pilot randomized trial of safety and feasibility in a public hospital in Brazil

Background

The effect of early mobilization after acute stroke is still unclear, although some studies have suggested improvement in outcomes. We conducted a randomized, single-blind, controlled trial seeking to evaluate the feasibility, safety, and benefit of early mobilization for patients with acute ischemic stroke treated in a public teaching hospital in Southern Brazil. This report presents the feasibility and safety findings for the pilot phase of this trial.

Methods

The primary outcomes were time to first mobilization, total duration of mobilization, complications during early mobilization, falls within 3 months, mortality within 3 months, and medical complications of immobility. We included adult patients with CT- or MRI-confirmed ischemic stroke within 48 h of symptom onset who were admitted from March to November 2012 to the acute vascular unit or general emergency unit of a large urban emergency department (ED) at the Hospital de Clínicas de Porto Alegre. The severity of the neurological deficit on admission was assessed by the National Institutes of Health Stroke Scale (NIHSS). The NIHSS and modified Rankin Scale (mRS, functional outcome) scores were assessed on day 14 or at discharge as well as at 3 months. Activities of daily living (ADL) were measured with the modified Barthel Index (mBI) at 3 months.

Results

Thirty-seven patients (mean age 65 years, mean NIHSS score 11) were randomly allocated to an intervention group (IG) or a control group (CG). The IG received earlier (p = 0.001) and more frequent (p < 0.0001) mobilization than the CG. Of the 19 patients in the CG, only 5 (26%) underwent a physical therapy program during hospitalization. No complications (symptomatic hypotension or worsening of neurological symptoms) were observed in association with early mobilization. The rates of complications of immobility (pneumonia, pulmonary embolism, and deep vein thrombosis) and mortality were similar in the two groups. No statistically significant differences in functional independence, disability, or ADL (mBI ≥85) were observed between the groups at the 3-month follow-up.

Conclusions

This pilot trial conducted at a public hospital in Brazil suggests that early mobilization after acute ischemic stroke is safe and feasible. Despite some challenges and limitations, early mobilization was successfully implemented, even in the setting of a large, complex ED, and without complications. Patients from the IG were mobilized much earlier than controls receiving the standard care provided in most Brazilian hospitals.

Functional Mobility Training for Individuals Admitted to Acute Care Following a Stroke: A Prospective Study

PURPOSE

This study describes current stroke care within hospital acute care settings.

METHOD

Twenty-two acute care hospital sites in Central South Ontario were mailed a survey exploring the prevalence of stroke admissions, use of protocols and policies, staff resources, stroke-specific training, and available equipment. Corresponding site data from the Canadian Institute for Health Information were also analyzed.

RESULTS

An 82% survey response rate was obtained. In 2003-2004, stroke admissions represented 1.9% of total admissions, with a mean admitting resource intensity weight of 1.99. Average length of stay was 12.5 days, with 3.4 of these days designated awaiting an alternate level of care. One third of the sites reported that they had no written guidelines on how to position or mobilize individuals following a stroke, and very few of the sites reported providing stroke-specific education.

CONCLUSION

The lack of a consistent coordinated approach to early mobilization and physical care for individuals admitted to an acute care setting following a stroke necessitates that new opportunities to coordinate educational resources and services to promote evidence-based practice in acute stroke care be pursued.

Physical Activity and Exercise Engagement in Patients Diagnosed with Transient Ischemic Attack and Mild/Non-disabling Stroke: A Commentary on Current Perspectives

Individuals diagnosed with a transient ischemic attack (TIA) or mild/non-disabling stroke are at high risk of cardiovascular or recurrent cerebrovascular (stroke, TIA) events. Pharmacological intervention (ie anti-platelet and anti-coagulant medication) is considered the cornerstone of secondary prevention care for this population group. However, recent research has explored the utility of non-pharmacological interventions (eg exercise, diet, education) in improving health outcomes and reducing the risk of secondary events in patients with TIA or mild/non-disabling stroke. This commentary discusses the efficacy of implementing exercise interventions as a part of the secondary care program for acute and non-acute TIA and stroke patients. Current perspectives and future research initiatives are also discussed.

When Should Physical Rehabilitation Commence after Stroke: A Systematic Review

Background

Knowing when to commence physical rehabilitation after stroke is important to ensure optimal benefit for stroke survivors and efficient health care. The aims of this review were to: determine the effects on mortality, function and complications when physical rehabilitation commences ‘early’ (within seven days of stroke); and describe the effects of early transfer to rehabilitation wards/hospitals when sustained rehabilitation is unavailable in acute stroke units.

Review summary

From 3751 potential articles we included 5 randomized controlled trials and 38 cohort studies. Meta-analysis was performed with 3 randomized controlled trials involving 159 people to investigate the effects of commencing physical rehabilitation within 24 h of stroke compared to 48 h. Commencing physical rehabilitation within 24 h trended towards greater mortality (Mantel-Haenszel odds ratio 2·58; 95% confidence interval 0·98 to 6·79, P = 0·06), with no differences in complications or health outcomes. The cohort studies provided evidence of benefits when physical rehabilitation was commenced on the day of admission ( n = 1), within 3 days of stroke ( n = 3), or ‘sooner rather than later’ (3 of 4 studies). The effect of earlier transfer to rehabilitation was reported in 32 cohort studies. In 23/26 (88%) cohort studies that accounted for age and stroke severity, results favored earlier transfer for improving post-stroke function, with no consensus on timeframes.

Conclusion

In summary, the benefits of commencing physical rehabilitation within 24 h of stroke remain unclear from the current literature. Commencing physical rehabilitation or transferring to rehabilitation services ‘early’ may provide better functional outcomes.

Mortality and real cause of death from the nonlesional intracerebral hemorrhage

Objective

The case fatality rate of nonlesional intracerebral hemorrhage (n-ICH) was high and not changed. Knowing the causes is important to their prevention; however, the reasons have not been studied. The aims of this study were to determine the cause of death, to improve the clinical outcomes.

Methods

We retrospectively analyzed consecutive cases of nonlesional intracerebral hemorrhage in a prospective stroke registry from January 2010 to December 2010.

Results

Among 174 patients (61.83±13.36, 28-90 years), 29 patients (16.7%) died during hospitalization. Most common cause of death was initial neurological damage (41.4%, 12/29). Seventeen patients who survived the initial damage may then develop various potentially fatal complications. Except for death due to the initial neurological sequelae, death associated with immobilization (such as pneumonia or thromboembolic complication) was the most common in eight cases (8/17, 47.1%). However, death due to early rebleeding was not common and occurred in only 2 cases (2/17, 11.8%). Age, initial Glasgow Coma Scale, and diabetes mellitus were statistically significant factors influencing mortality (p<0.05).

Conclusion

Mortality of n-ICH is still high. Initial neurological damage is the most important factor; however, non-neurological medical complications are a large part of case fatality. Most cases of death of patients who survived from the first bleeding were due to complications of immobilization. These findings have implications for clinical practice and planning of clinical trials. In addition, future conduct of a randomized study will be necessary in order to evaluate the benefits of early mobilization for prevention of immobilization related complications.

Cerebral blood flow velocity changes during upright positioning in bed after acute stroke: an observational study

OBJECTIVES

National guidelines recommend mobilisation in bed as early as possible after acute stroke. Little is known about the influence of upright positioning on real-time cerebral flow variables in patients with stroke. We aimed to assess whether cerebral blood flow velocity (CBFV) changes significantly after upright positioning in bed in the acute stroke phase.

DESIGN

Observational study.

PARTICIPANTS

47 patients with acute ischaemic stroke measured in the subacute phase after symptom onset and 20 healthy controls.

PRIMARY AND SECONDARY OUTCOME MEASURES

We recorded postural changes in bilateral transcranial Doppler (primary outcome) and simultaneously recorded near-infrared spectroscopy, end-tidal CO2, non-invasive blood pressure data and changes in neurological status (secondary outcomes).

METHODS

Postures included the supine, half sitting (45°), sitting (70°) and Trendelenburg (-15°) positions. Using multilevel analyses, we compared postural changes between hemispheres, outcome groups (using modified Rankin Scale) as well as between patients and healthy controls.

RESULTS

The mean patient age was 62±15 years and median National Institute of Health Stroke Scale score on admission was 7 (IQR 5-14). Mean proportional CBFV changes on sitting were not significantly different between healthy controls and affected hemispheres in patients with stroke. No significant differences were found between affected and unaffected stroke hemispheres and between patients with unfavourable and favourable outcomes. During upright positioning, no neurological worsening or improvement was observed in any of the patients.

CONCLUSIONS

No indications were found that upright positioning in bed in mild to moderately affected patients with stroke compromises flow and (frontal)oxygenation significantly during the subacute phase of stroke. Supine or Trendelenburg positioning does not seem to augment real-time flow variables.

Tolerance of a standing tilt table protocol by patients an inpatient stroke unit setting: a pilot study

BACKGROUND AND PURPOSE

To describe and examine physiologic and self-reported indices of tolerance to a standing tilt table protocol (STTP) among patients following an acute stroke.

METHODS

We undertook a prospective, observational pilot study of patients admitted to a stroke unit of a single academic medical center. A clinical protocol for the use of the tilt table was developed and applied to subjects in the acute phase following a stroke. The protocol involved a stepwise process to gradually raise the subject into a standing position on the tilt table platform, at 10° intervals from 60° to 90°. Tolerance of the STTP was operationally defined as the ability to sustain 60° or greater of tilt table inclination for a minimum of 5 minutes, without signs or symptoms of intolerance. Specific measures recorded were frequencies of the highest angle achieved, the duration of standing time tolerated, and physiologic response.

RESULTS

Thirty-six patients with ischemic or hemorrhagic stroke (22 women and 14 men) aged 24 to 87 (mean age = 62, SD = 16) years participated in a single trial of the STTP. Fifty-three percent of subjects (N = 19) attained 60° or higher on the tilt table, with a mean total standing time of approximately 9 minutes.

DISCUSSION AND CONCLUSIONS

This pilot study suggests that the use of a tilt table is well tolerated among patients in the acute stroke phase and may be an effective tool for introducing early upright mobilization to a medically fragile patient population.Video Abstract available (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A35) for more insights from the authors.

Short-term and long-term stroke survival: the belgrade prognostic study

Background and Purpose

The aims of this study were to determine the 28-day and 1-year survival rates after first-ever ischemic stroke and to identify their baseline predictors.

Methods

We prospectively and consecutively collected data on 300 patients with first-ever acute ischemic stroke admitted to 2 major neurological institutions for cerebrovascular diseases in Belgrade during March 2008. The Kaplan-Meier method was used to estimate the cumulative 28-day and 1-year survival rates, and the predictive values of different variables were assessed by Cox proportional-hazards regression model.

Results

The cumulative 28-day and 1-year survival rates of ischemic stroke patients in the cohort were 81.0% and 78.3%, respectively. The multivariate predictive model revealed that hypertension (p=0.017), National Institutes of Health Stroke Scale score (p=0.001), and in-hospital medical complications (p=0.029) were significant unfavorable independent outcome predictors, while early physical therapy (p=0.001) was a significant favorable prognostic factor for the 28-day mortality in our patients. Multivariate Cox regression analysis showed that age (p=0.001), National Institutes of Health Stroke Scale score (p=0.001), and in-hospital complications (p=0.008) remained significant predictors of 1-year mortality.

Conclusions

The findings support the need for optimal control of vascular risk factors and treatment of atherosclerotic disease as well as appropriate prevention and management of in-hospital complications of stroke.

Outcome After Mobilization Within 24 Hours of Acute Stroke

Background and Purpose—

Very early mobilization (VEM) is considered to contribute to the beneficial effects of stroke units, but there are uncertainties regarding the optimal time to start mobilization. We hypothesized that VEM within 24 hours after admittance to the hospital would reduce poor outcome 3 months poststroke compared with mobilization between 24 and 48 hours.

Methods—

We conducted a prospective, randomized, controlled trial with blinded assessment at follow-up. Patients admitted to the stroke unit within 24 hours after stroke were assigned to either VEM within 24 hours of admittance or mobilization between 24 and 48 hours (control group). Primary outcome was the proportion of poor outcome (modified Rankin scale score, 3–6), whereas secondary outcomes were death rate, change in neurological impairment (National Institutes of Health Stroke Scale score), and dependency (Barthel Index 0–17).

Results—

Fifty-six patients were included (mean age±SD, 76.9±9.4 years), 27 were in the VEM group and 29 were in the control group. VEM patients had nonsignificant higher odds (adjusted for age and National Institutes of Health Stroke Scale score on admission) of poor outcome (OR, 2.70; 95% CI, 0.78–9.34; P =0.12), death (OR, 5.26; 95% CI, 0.84–32.88; P =0.08), and dependency (OR, 1.25; 95% CI, 0.36–4.34; P =0.73). The control group, having milder strokes (National Institutes of Health Stroke Scale score±SD: control group, 7.5±4.2; VEM, 9.2±6.5; P =0.26), had better neurological improvement ( P =0.02).

Conclusions—

We identified a trend toward increased poor outcome, death rate, and dependency among patients mobilized within 24 hours after hospitalization, and an improvement in neurological functioning in favor of patients mobilized between 24 and 48 hours. Very early or delayed mobilization after acute stroke is still undergoing debate, and results from ongoing larger trials are required.

Stroke Rehabilitation

The need for stroke rehabilitation will lessen if stroke incidence declines and acute stroke medical and surgical treatment improves. The burden of stroke will also lessen as effective rehabilitation services (stroke rehabilitation units) and interventions are widely implemented. Despite the considerable amount of evidence available, implementation has been slow. Improvement in stroke rehabilitation will require continued professional advocacy, supported by local and national audit and future focused research.

Early mobilization out of bed after ischaemic stroke reduces severe complications but not cerebral blood flow: a randomized controlled pilot trial

Objective: To evaluate whether early mobilization after acute ischaemic stroke is better than delayed mobilization with regard to medical complications and if it is safe in relation to neurological function and cerebral blood flow.

Design: Randomized controlled pilot trial of early versus delayed mobilization out of bed with incidence of severe complications as the primary outcome.

Setting: Acute stroke unit in the neurology department of a University Hospital.

Participants: Fifty patients after ischaemic stroke with a National Institutes of Health Stroke Scale (NIHSS) score >6 were recruited.

Intervention: All patients were treated with physiotherapy immediately after their admission. In the early protocol patients were mobilized out of bed after 52 hours, in the delayed protocol after seven days.

Results: Eight out of 50 randomized patients were excluded from the per-protocol analysis because of early transfer to other hospitals. There were 2 (8%) severe complications in the 25 early mobilization patients and 8 (47%) in the 17 delayed mobilization patients ( P < 0.006). There were no differences in the total number of complications or in clinical outcome. In the 26 patients (62%) who underwent serial transcranial Doppler ultrasonography, no blood flow differences were found.

Conclusion: We found an apparent reduction in severe complications and no increase in total complications with an early mobilization protocol after acute ischaemic stroke. No influence on neurological three-month outcomes or on cerebral blood flow was seen. These results justify larger trials comparing mobilization protocols with possibly even faster mobilization out of bed than explored here.

Does evidence really matter? Professionals' opinions on the practice of early mobilization after stroke

INTRODUCTION

Early mobilization after stroke may be important for a good outcome and it is currently recommended in a range of international guidelines. The evidence base, however, is limited and clear definitions of what constitutes early mobilization are lacking.

AIMS

To explore stroke care professionals' opinions about (1) when after stroke, first mobilization should take place, (2) whether early mobilization may affect patients' final outcome, and (3) what level of evidence they require to be convinced that early mobilization is beneficial.

METHODS

A nine-item questionnaire was used to interview stroke care professionals during a conference in Sydney, Australia.

RESULTS

Among 202 professionals interviewed, 40% were in favor of mobilizing both ischemic and hemorrhagic stroke patients within 24 hours of stroke onset. There was no clear agreement about the optimal time point beyond 24 hours. Most professionals thought that patients' final motor outcome (76%), cognitive outcome (57%), and risk of depression (75%) depends on being mobilized early. Only 19% required a large randomized controlled trial or a systematic review to be convinced of benefit.

CONCLUSION

The spread in opinion reflects the absence of clear guidelines and knowledge in this important area of stroke recovery and rehabilitation, which suggests further research is required.

["Time is brain": only in the acute phase of stroke?]

INTRODUCTION AND OBJECTIVE

In Spain, stroke is the leading cause of death in women as well as the leading cause of disability in adults. This translates into a huge human and economic cost. In recent years there have been significant advances both in the treatment of acute stroke and in the neuro-rehabilitation process; however, it is still unclear when the best time is to initiate neurorehabilitation and what the consequences of delaying treatment are. To test the effect of a single day delay in the onset of neurorehabilitation on functional improvement achieved, and the influence of that delay in the rate of institutionalisation at discharge.

METHODS

A retrospective study of patients admitted to Parkwood Hospital's Stroke Neurorehabilitation Unit (UNRHI) (University of Western Ontario, Canada) between April 2005 and September 2008 was performed. We recorded age, Functional Independence Measurement (FIM) score at admission and discharge, the number of days between the onset of stroke and admission to the Neurorehabilitation Unit and discharge destination.

RESULTS

After adjustment for age and admission FIM, we found a significant association between patient functional improvement (FIM gain) and delay in starting rehabilitation. We also observed a significant correlation between delay in initiating therapy and the level of institutionalisation at discharge.

CONCLUSIONS

A single day delay in starting neurorehabilitation affects the functional prognosis of patients at discharge. This delay is also associated with increased rates of institutionalisation at discharge.

An Early Mobilization Protocol Successfully Delivers More and Earlier Therapy to Acute Stroke Patients

Background. The optimal physical therapy dose in acute stroke care is unknown. The authors hypothesized that physical therapy would be significantly different between treatment arms in a trial of very early and frequent mobilization (VEM) and that immobility-related adverse events would be associated with therapy dose. Methods. This study was a single-blind, multicenter, randomized control trial. Patients admitted to a stroke unit <24 hours of stroke randomized to standard care (SC) or intervention, SC plus additional early out-of-bed therapy (VEM). Timing, amount, and type of therapy recorded throughout the trial. Adverse events were recorded to 3 months. Results. A total of 71 patients (SC n = 33, VEM n = 38) received 788 therapy sessions in the first 2 weeks of stroke. Schedule (hours to first mobilization, dose per day, frequency and session duration) and nature (percentage out-of-bed activity) of therapy differed significantly between groups ( P ≤ .001 for all components). Mobilization was earlier, happened on average 3 times per day in those receiving VEM, with the proportion of out-of-bed activity double in VEM session (median SC 42.5%, VEM 85.5%). SC consisted of 17 minutes of occupational and physiotherapy per day and was the same between groups. Number of immobility-related adverse events 3 months poststroke was not associated with therapy dose or frequency. Conclusions. The authors detailed usual care and intervention therapy provided to patients from admission to 14 days after stroke. The therapy schedule was markedly different in the intervention arm, but whether this schedule reduces complications or improves outcome is unknown.

‘Better Wear Out Sheets than Shoes’: A Survey of 202 Stroke Professionals' Early Mobilisation Practices and Concerns

Background

Stroke unit care improves the outcome for patients. One component responsible for this may be that patients are mobilised earlier and more intensively. An ongoing randomised controlled trial is investigating the potential benefits of early mobilisation, but currently there is limited evidence for the practice. Therefore, current practices may be driven by historical precedent and/or clinical opinion, and varying approaches to mobilisation are likely. This study aims to examine different health professionals' concerns regarding early mobilisation in acute stroke. In this study, early mobilisation was defined as frequent out of bed activities within the first 24 h after stroke onset.

Methods

A nine-item anonymous questionnaire exploring benefits and harms with early mobilisation after stroke was used during interviews of stroke care professionals attending the annual Australasian stroke conference in 2008.

Results

The survey was completed by 202 professionals, representing 38% of all conference attendees. Sixty-five per cent were females, 50% under 40-years old, 46% worked in acute stroke and 31% in rehabilitation. Thirty-five per cent were nurses, 26% medical doctors, 19% physiotherapists and 12% occupational therapists. Two-thirds had <10-years experience with stroke. Sixty per cent of the surveyed professionals had concerns about early mobilisation and there were significantly more professionals concerned about early mobilisation for haemorrhagic (59%) than ischaemic (23%) stroke patients.

Conclusion

Our study shows that most clinicians had concerns in relation to early mobilisation of stroke patients and more clinicians had concerns for haemorrhagic than for ischaemic stroke. The evidence underlying these concerns is shallow.

Very early versus delayed mobilisation after stroke

BACKGROUND

Very early mobilisation is performed in some stroke units and recommended in acute stroke clinical guidelines. It is unclear whether very early mobilisation independently improves outcome after stroke.

OBJECTIVES

To determine the benefits and harms of very early mobilisation (commenced within 48 hours of stroke) compared with conventional care.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched April 2008). In addition, we searched 25 databases including the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2007), MEDLINE (1950 to August 2007), EMBASE (1980 to September 2007), CINAHL (1982 to December 2006), and AMED (1985 to January 2007). We also searched relevant ongoing trials and research registers (searched January 2007) and the Chinese medical database Wanfangdata (searched March 2007), handsearched journals, searched reference lists and contacted researchers in the field.

SELECTION CRITERIA

Unconfounded RCTs of acute stroke patients, comparing an intervention group that started out of bed mobilisation within 48 hours of stroke and aimed to reduce time to first mobilisation and/or increase the amount or frequency (or both) of mobilisation, with conventional care.

DATA COLLECTION AND ANALYSIS

One review author eliminated obviously irrelevant records; two review authors independently applied selection criteria to remaining studies. The primary outcome was death or poor outcome (dependency or institutionalisation) at the end of scheduled follow up. Secondary outcomes included mortality, dependency, institutionalisation, activities of daily living (ADLs), quality of life, time to walking, adverse events (e.g. deep vein thrombosis) and patient mood.

MAIN RESULTS

One study, involving 71 participants, was included. In this study the experimental group had earlier and more frequent mobilisation than the control group (median 18.1 hours post stroke for experimental group versus 30.8 hours control; 167 minutes of mobilisation (interquartile range (IQR) 62 to 305) during admission for experimental group versus 69 (IQR 31 to 115) minutes control). Fewer patients who received early and frequent mobilisation were dead or disabled at three months, but this was not statistically significant and the confidence intervals were wide (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.25 to 1.79, P = 0.42). No significant difference on any secondary outcomes of interest were found.

AUTHORS' CONCLUSIONS

We found insufficient evidence to support or refute the efficacy of routine very early mobilisation after stroke, compared with conventional care. More research is required to determine the benefits and harms of very early mobilisation after stroke.

Guidelines for management of ischaemic stroke and transient ischaemic attack 2008

This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation.

A very early rehabilitation trial for stroke (AVERT): phase II safety and feasibility

BACKGROUND AND PURPOSE

Very early rehabilitation, with an emphasis on mobilization, may contribute to improved outcomes after stroke. We hypothesized that a very early rehabilitation protocol would be safe and feasible.

METHODS

We performed a randomized, controlled trial with blinded outcome assessment. Patients at <24 hours after stroke were recruited from 2 Melbourne metropolitan stroke units. Patients were randomly assigned to receive standard care (SC) or SC plus very early mobilization (VEM) until discharge or 14 days (whichever was sooner). The primary safety outcome was the number of deaths at 3 months. The primary feasibility outcome was a higher "dose" of mobilization achieved in VEM. Secondary safety outcomes included adverse events (including falls and early neurologic deterioration), compliance with physiologic monitoring criteria, and patient fatigue after interventions. Secondary feasibility outcomes included "contamination" of standard care.

RESULTS

Overall, 18% of patients screened were suitable for recruitment. Seventy-one patients were recruited and randomized, with 2 dropouts by 12 months. The majority experienced ischemic strokes (87%). The group mean+/-SD age was 74.7+/-12.5 years, and 58% (n=41) had a National Institutes of Health Stroke Scale score >7. There was no significant difference in the number of deaths between groups (SC, 3 of 33; VEM, 8 of 38; P=0.20). Almost all deaths occurred in patients with severe stroke. Secondary safety outcomes were similar between groups. The intervention protocol was successfully delivered, achieving VEM dose targets (double SC, P=0.003) and faster time to first mobilization (P<0.001).

CONCLUSIONS

VEM of patients within 24 hours of acute stroke appears safe and feasible. Intervention efficacy and cost-effectiveness are currently being tested in a large randomized, controlled trial.