Outcome After Mobilization Within 24 Hours of Acute Stroke

A systematic review and meta-analysis of clinical efficacy of early and late rehabilitation interventions for ischemic stroke

INTRODUCTION

At present, stroke has become the first cause of death and disability among Chinese adults. With the coming of the aging population in China, the disease burden brought by stroke will be increasingly aggravated. And stroke is a leading cause of disability. There is a golden plastic period after stroke, during which timely and safe intervention and rehabilitation therapy can effectively improve the disability status. However, there is still controversy about the duration of interventional rehabilitation after stroke. This study conducted a meta-analysis on the influence of intervention in early and late ischemic stroke rehabilitation.

METHOD

Chinese language databases such as CNKI, Wanfang, and VIP, and English language databases such as Embase, PubMed, Web of Science, and The Cochrane Library were searched, and RCT related to early and late rehabilitation of ischemic stroke from the establishment of the database to October 2023 was collected. Review Manager 5.4.1 was used for relevant analysis. The main outcomes were Barthel Index or Modified Barthel Index, Fugl-Meyer Assessment scale, NIHSS, China Stroke Scale. Standardized Mean Difference (SMD) was used as an effective indicator of continuity variables, and the estimated interval was expressed by 95% confidence interval (CI).

RESULTS

A total of 1908 patients were included in 16 studies. The results showed that, compared with late rehabilitation, early rehabilitation improved clinical efficacy. Barthel Index or Modified Barthel Index score was [SMD = 1.40, 95%CI(1.16,1.63), p < 0.001]; the score of Fugl-Meyer Assessment Scale was [SMD = 1.18, 95%Cl (0.85, 1.52), P < 0.001]; the score of NIHSS was [SMD= -0.44, 95% CI(-0.65, -0.24), P < 0.001]; the result of China Stroke Scale score was [SMD= -0.37, 95%CI(-0.56, -0.18), P < 0.001].

CONCLUSION

In comparison with late rehabilitation, early rehabilitation can significantly improve self-care abilities, daily activities, and neurological functions of ischemic stroke patients.

TRIAL REGISTRATION

This meta-analysis has been registered with Prospero, and the registration number is CRD42022309911. The registration period is March 22, 2022.

Impact of Early Mobilization on Patients With Acute Ischemic Stroke Treated With Thrombolysis or Thrombectomy: A Randomized Controlled Trial

BACKGROUND

Early mobilization (EM) within 24 to 72 hours post-stroke may improve patients' performance and ability. However, after intravenous thrombolysis (IVT) or mechanical thrombectomy (MT), the increased risk of hemorrhagic complications impacts the implementation of early out-of-bed mobilization. Few studies have investigated EM after IVT or MT for acute ischemic stroke (AIS), and its impact in these patients is unknown.

OBJECTIVE

To investigate the effect of EM on AIS treated with IVT or MT.|.

METHODS

We recruited 122 patients with first AIS; 60 patients were treated with IVT, and 62 patients were treated with MT. For each IVT and MT cohort, the control groups received standard early rehabilitation, and the intervention groups received an EM protocol. The training lasted 30 minutes/day, 5 days/week until discharge.

MAIN OUTCOMES MEASURES

The effectiveness of the interventions was evaluated using the motor domain of the Functional Independence Measure (FIM-motor) and the Postural Assessment Scale for Stroke Patients (PASS) at baseline, 2-week, 4-week, and 3-month post-stroke, the Functional Ambulation Category 2-week post-stroke, and the total length of stay at the stroke center.

RESULTS

Both IVT and MT treatment groups showed improved FIM-motor and PASS scores over time; however, only the IVT EM group had significantly improved FIM-motor performance within 1 month after stroke than the control group. Conclusion. An EM protocol with the same intervention time and session frequency per day as in the standard care protocol was effective in improving the functional ability of stroke patients after IVT.

Activity monitoring of stroke patients by physiotherapist and caregivers in a hospital setting: A pilot study

Background

Activity monitoring is a necessary technique to ensure stroke survivors' activity levels in the hospital are within optimal levels as this is important for enhanced motor recovery. However, this could be time-consuming for healthcare professionals like physiotherapists. Activity monitoring by caregivers could be an alternate option. Therefore, our aim was to compare the activity monitoring of stroke survivors by caregivers and physiotherapists during early phase in a hospital setting.

Methods

An observation study was carried out in the neuroscience ward in a tertiary care hospital among 17 stroke survivors. Physiotherapist and caregivers were instructed to use an activity log chart that was developed during previous research conducted by the same authors for observing the activities performed by the patients every 15 minutes from 8 AM to 5 PM across one day. Data collected were analysed using Stata 15. Kappa statistics were carried out to determine the agreement of the observations between the two raters.

Results

A total of 10 male and seven female caregivers of stroke survivors with a mean age of 40.11 ± 9.2 years and a trained physiotherapist participated in the study. A total of 272 observations of caregivers were in agreement with that of the physiotherapist. Inter-rater Kappa statistics showed 60% agreement between the physiotherapist and the caregivers (p<0.05).

Conclusions

There was moderate agreement between the physiotherapist and caregiver for activity monitoring of stroke survivors. This suggests behavioural mapping by caregivers may be a potential alternative solution in healthcare settings.

Factors influencing the willingness to participate in rehabilitation in patients with subacute stroke

OBJECTIVE

The aim of this study was to examine the parameters that may influence the willingness of patients to participate in post-stroke rehabilitation.

METHODS

Patients in the subacute phase of stroke who underwent inpatient rehabilitation for one month were included in this study. The primary outcome measure was the level of rehabilitation participation as measured on the Pittsburgh Rehabilitation Participation Scale (PRPS). Other outcome measures evaluated were Mini-Mental State Examination (MMSE) for cognitive functions, Brunnstrom stage for motor recovery, modified Rankin Scale (mRS) for disability, Functional Independence Measure for functionality, Pittsburgh Sleep Quality Index for sleep quality, and Beck Depression Inventory for emotional state.

RESULTS

A total of 38 patients with first-time stroke were studied. A negative correlation was found between the participation in rehabilitation and body mass index (BMI) (r: -0.398p = 0.012), myocardial infarction (MI) history (r: -0.387p = 0.015) and mRS (r: -0.351p = 0.031), while a positive correlation was determined with MMSE (r: 0.432P = 0.007). A 1-unit increase in BMI, MI history, and mRS resulted in a 0.176, 0.673, and 0.294-unit decrease in participation in rehabilitation, respectively. In addition, a 1-unit increase in MMSE provided an increase of 0.606-unit in participation.

CONCLUSION

BMI within normal limits, prevention/treatment of cardiovascular diseases, and well-being of physical and cognitive functions might be the factors that positively influence participation in rehabilitation process. We consider that it would be appropriate to evaluate these parameters with particular emphasis in stroke patients in the subacute period to be rehabilitated.

Nonpharmacological Treatments for Hospitalized Patients with Stroke: A Nuanced Approach to Prescribing Early Activity

Stroke remains a leading cause of adult disability. To date, hyperacute revascularization procedures reach 5-10% of stroke patients even in high resource health systems. There is a limited time window for brain repair after stroke, and therefore, the activities such as prescribed exercise in the earliest period will likely have long-term significant consequences. Clinicians who provide care for hospitalized stroke patients make treatment decisions specific to activity often without guidelines to direct these prescriptions. This requires a balanced understanding of the available evidence for early post-stroke exercise and physiological principles after stroke that drive the safety of prescribed exercise. Here, we provide a summary of these relevant concepts, identify gaps, and recommend an approach to prescribing safe and meaningful activity for all patients with stroke. The population of thrombectomy-eligible stroke patients can be used as the exemplar for conceptualization.

Development and Implementation of a New Model of Care for Patients With Stroke, Acute Hospital Rehabilitation Intensive SErvices: Leveraging a Multidisciplinary Rehabilitation Team

ABSTRACT

The optimal timing and intensity of early rehabilitation remain uncertain. The literature has stated that too early high-intensity mobility within 24 hours can result in poor outcomes as compared with the 24- to 48-hour poststroke (Stroke 2012;43:2389-94. Stroke 2004;35:1005-9). However, few studies have shown that mobilizing patients a few times per day can have positive results (Stroke 2004;35:1005-9. Cerebrovasc Dis 2010;29:352-60). In addition to mobility impairments, many patients after stroke have dysphagia, aphasia, and cognitive-linguistic deficits. To date, there is limited literature on early rehabilitation in these areas. Here, we describe a program of enhanced rehabilitation in the acute care hospital. In this enhanced model of care, our team delivers up to six sessions of therapy per day focused on the patient's deficits. A patient can receive up to two sessions of each discipline daily to include physical therapy, occupational therapy, and speech language pathology. The model emphasizes team collaboration between therapy disciplines, physiatry, nursing, and neurology accomplished through a daily therapy schedule, rehabilitation huddle, and direct communication before and after therapy sessions. With this model, we aim to enhance coordination of care resulting in improved patient satisfaction and, ultimately, recovery.

Synergistic therapeutic effects of intracerebral transplantation of human modified bone marrow-derived stromal cells (SB623) and voluntary exercise with running wheel in a rat model of ischemic stroke

BACKGROUND

Mesenchymal stromal cell (MSC) transplantation therapy is a promising therapy for stroke patients. In parallel, rehabilitation with physical exercise could ameliorate stroke-induced neurological impairment. In this study, we aimed to clarify whether combination therapy of intracerebral transplantation of human modified bone marrow-derived MSCs, SB623 cells, and voluntary exercise with running wheel (RW) could exert synergistic therapeutic effects on a rat model of ischemic stroke.

METHODS

Wistar rats received right transient middle cerebral artery occlusion (MCAO). Voluntary exercise (Ex) groups were trained in a cage with RW from day 7 before MCAO. SB623 cells (4.0 × 105 cells/5 μl) were stereotactically injected into the right striatum at day 1 after MCAO. Behavioral tests were performed at day 1, 7, and 14 after MCAO using the modified Neurological Severity Score (mNSS) and cylinder test. Rats were euthanized at day 15 after MCAO for mRNA level evaluation of ischemic infarct area, endogenous neurogenesis, angiogenesis, and expression of brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF). The rats were randomly assigned to one of the four groups: vehicle, Ex, SB623, and SB623 + Ex groups.

RESULTS

SB623 + Ex group achieved significant neurological recovery in mNSS compared to the vehicle group (p < 0.05). The cerebral infarct area of SB623 + Ex group was significantly decreased compared to those in all other groups (p < 0.05). The number of BrdU/Doublecortin (Dcx) double-positive cells in the subventricular zone (SVZ) and the dentate gyrus (DG), the laminin-positive area in the ischemic boundary zone (IBZ), and the mRNA level of BDNF and VEGF in SB623 + Ex group were significantly increased compared to those in all other groups (p < 0.05).

CONCLUSIONS

This study suggests that combination therapy of intracerebral transplantation SB623 cells and voluntary exercise with RW achieves robust neurological recovery and synergistically promotes endogenous neurogenesis and angiogenesis after cerebral ischemia, possibly through a mechanism involving the up-regulation of BDNF and VEGF.

Efficacy and safety of very early mobilization after thrombolysis in acute ischemic stroke: a randomized clinical trial

BACKGROUND

Stroke has a deleterious impact on human health due to its high incidence, degree of disabling sequelae and mortality, constituting one of the main causes of death and disability worldwide.

OBJECTIVES

This study aimed to assess the efficacy and safety of very early mobilization (VEMG) after thrombolysis in functional recovery in patients with acute ischemic stroke.

METHODS

The present study was an open, prospective, randomized study, with no blinded outcome, carried out in the stroke unit of a tertiary referral hospital located in Salvador-Bahia, Brazil. The primary outcome was the level of functional independence. Secondary outcomes were functional mobility, balance, complications within 7 days of hospitalization and 90 days after hospital discharge, and length of stay.

OUTCOMES

A total of 104 patients with ischemic stroke who received thrombolytic treatment between August 2020 and July 2021 were prospectively recruited to the study. Of these, 51 patients received VEMG within 24 h of the ictus and another 53 patients receiving usual care (UCG) with mobilization 24 h after the ictus. When compared to the usual care, the VEMG group was not associated with a significant reduction in the risk of the primary outcome (relative risk [95% confidence intervals]: 0.74 [0.339-1.607]) or any of the secondary outcomes.

CONCLUSION

In this study, the strategy of early mobilization after thrombolysis in ischemic stroke was safe, but without evidence of short-term benefit. Brazilian Registry of Clinical Trials under the registry (registry number: RBR-8bgcs3).

Safety of early rehabilitation in patients with aneurysmal subarachnoid hemorrhage: A retrospective cohort study

OBJECTIVE

To investigate the safety and efficacy of early rehabilitation in patients with aneurysmal subarachnoid hemorrhage (aSAH) patients.

METHODS

One hundred eleven patients with aSAH admitted between April 2015 and March 2019, were retrospectively evaluated. The early rehabilitation program was introduced in April 2017 to actively promote mobilization and walking training for aSAH patients. Therefore, patients were divided into two groups (The conventional group (n = 55) and the early rehabilitation group (n == 56). Clinical characteristics, mobilization progression, and treatment variables were analyzed. Complications (rebleeding, symptomatic cerebral vasospasm, hydrocephalus, disuse complications,) and a modified Rankin Scale (mRS) at 90 days were compared in two groups. Factors associated with favorable outcomes (mRS≤2) at 90 days were also assessed.

RESULTS

The early rehabilitation group had a significantly shorter span to first walking (9 vs. 5 days; P = 0.007). The prevalence of complications was not significantly increased in the early rehabilitation group. Approximately 40% of patients in both groups had pneumonia and urinary tract infections but significantly reduced antibiotic-administration days (13 vs. 6 days; P < 0.001). mRS at 90 days also showed significant improvement in the early rehabilitation group (3 vs. 2; P=0.01). Multivariate logistic regression analysis of favorable outcomes associated that the administration of the early rehabilitation program has a significant independent factor (odds ratio, 3.03; 95% confidence interval, 1.1-8.37).

CONCLUSIONS

Early rehabilitation for patients with aSAH can be feasible without increasing complication occurrences. The early rehabilitation program with active mobilization and walking training reduced antibiotic use and was associated with improved independence.

Rehabilitation of visual perception in cortical blindness

Blindness is a common sequela after stroke affecting the primary visual cortex, presenting as a contralesional, homonymous, visual field cut. This can occur unilaterally or, less commonly, bilaterally. While it has been widely assumed that after a brief period of spontaneous improvement, vision loss becomes stable and permanent, accumulating data show that visual training can recover some of the vision loss, even long after the stroke. Here, we review the different approaches to rehabilitation employed in adult-onset cortical blindness (CB), focusing on visual restoration methods. Most of this work was conducted in chronic stroke patients, partially restoring visual discrimination and luminance detection. However, to achieve this, patients had to train for extended periods (usually many months), and the vision restored was not entirely normal. Several adjuvants to training such as noninvasive, transcranial brain stimulation, and pharmacology are starting to be investigated for their potential to increase the efficacy of training in CB patients. However, these approaches are still exploratory and require considerably more research before being adopted. Nonetheless, having established that the adult visual system retains the capacity for restorative plasticity, attention recently turned toward the subacute poststroke period. Drawing inspiration from sensorimotor stroke rehabilitation, visual training was recently attempted for the first time in subacute poststroke patients. It improved vision faster, over larger portions of the blind field, and for a larger number of visual discrimination abilities than identical training initiated more than 6 months poststroke (i.e., in the chronic period). In conclusion, evidence now suggests that visual neuroplasticity after occipital stroke can be reliably recruited by a range of visual training approaches. In addition, it appears that poststroke visual plasticity is dynamic, with a critical window of opportunity in the early postdamage period to attain more rapid, more extensive recovery of a larger set of visual perceptual abilities.

Cultural and linguistic adaptation of the Oxford Cognitive Screen to the Spanish population

INTRODUCTION

Stroke is the sixth leading cause of disability in Spain. Patients may present motor, sensory, or cognitive sequelae, which can be minimised with early treatment. To this end, there is a need for quick-to-administer assessment tools to evaluate deficits in these areas. The Oxford Cognitive Screen (OCS) is a brief test specifically designed to assess cognitive function in patients with stroke. Our aim in this study is to report the linguistic and cultural adaptation of a Spanish-language version of the test (OCS-S).

METHODS

The linguistic validation was conducted with a process of double translation and 10 consensus meetings of the multidisciplinary research team. We also performed 3 pilot studies, with 5 potential users, 23 healthy individuals, and 23 patients with stroke (ischaemic in 61% of cases and haemorrhagic in 39%), respectively; participants were aged between 31 and 88 years.

RESULTS

The OCS-S includes the 10 subtests, the coding of responses, and the scoring system from the original version. We modified and extended the instructions for administration in order to ensure the reliability of the content and its application. Five tasks were modified (images, numbers, and sentences) and the praxis subtest was modified to evaluate both hands. The pilot studies confirmed comprehension in the target population, independently of any cognitive problems.

CONCLUSION

The OCS-S is conceptually and linguistically equivalent to the original test, enabling psychometric assessment and application of the test in the Spanish population. The OCS-S may be a useful screening tool for quickly assessing cognitive function after stroke.

Clinical Evaluation of Different Treatment Strategies for Motor Recovery in Poststroke Rehabilitation during the First 90 Days

Background: Motor recovery after stroke is based on neuronal plasticity and the structural reorganization of the brain. Questions are debated about the proper moment to start rehabilitation in the acute period of stroke, the significance of rehabilitation interventions during the so-called “plastic window”, and the advantages of modern and traditional programs. The aims of this study were to evaluate the role of different rehabilitation strategies and their combinations for motor recovery and the impact on functional disability by way of neurological and functional outcomes 3 months after ischemic stroke. Methods: We used three rehabilitation approaches: early rehabilitation from the first day of stroke (Phase I), traditional exercise programs (Phase II), and an author’s new method of biofeedback rehabilitation using motion sensors and augmented reality (AR) rehabilitation (Phase III). Clinical and functional outcomes were measured on the 90th day after stroke. We developed algorithms for quantifying the quality of movements during the execution of tasks in the motor domains of the AR rehabilitation program. Results: Phase I of rehabilitation led to an improvement in functional independence, and the recovery of motor functions of the extremities with an absence of mortality and clinical deterioration. AR rehabilitation led to significant improvement both with respect to clinical and functional scores on scales and to variables reflecting the quality of movements. Patients who were actively treated during Phases II and III achieved the same final level of motor recovery and functional outcomes as that of participants who had only received AR rehabilitation during Phase III. Patients who underwent outpatient observation after Phase I showed a deficit of spontaneous motor recovery on the 90th day after stroke. Conclusions: Early rehabilitation was successful but was not enough; rehabilitation programs should be carried out throughout the entire “sensitive period” of poststroke plasticity. The newly developed AR biofeedback motion training is effective and safe as a separate rehabilitation method in the early recovery period of moderately severe, hemiparalytic, and ischemic stroke. These two rehabilitation approaches must be applied together or after each other, not instead of each other, as shown in clinical practice.

Sex Disparities in Enrollment in Recent Randomized Clinical Trials of Acute Stroke: A Meta-analysis

Importance

The underenrollment of women in randomized clinical trials represents a threat to the validity of the evidence supporting clinical guidelines and potential disparities in access to novel treatments.

Objective

To determine whether women were underenrolled in contemporary randomized clinical trials of acute stroke therapies published in 9 major journals after accounting for their representation in underlying stroke populations.

Data Sources

MEDLINE was searched for acute stroke therapeutic trials published between January 1, 2010, and June 11, 2020.

Study Selection

Eligible articles reported the results of a phase 2 or 3 randomized clinical trial that enrolled patients with stroke and/or transient ischemic attack and examined a therapeutic intervention initiated within 1 month of onset.

Data Extraction

Data extraction was performed by 2 independent authors in duplicate. Individual trials were matched to estimates of the proportion of women in underlying stroke populations using the Global Burden of Disease database.

Main Outcomes and Measures

The primary outcome was the enrollment disparity difference (EDD), the absolute difference between the proportion of trial participants who were women and the proportion of strokes in the underlying disease populations that occurred in women. Random-effects meta-analyses of the EDD were performed, and multivariable metaregression was used to explore the associations of trial eligibility criteria with disparity estimates.

Results

The search returned 1529 results, and 115 trials (7.5%) met inclusion criteria. Of 121 105 randomized patients for whom sex was reported, 52 522 (43.4%) were women. The random-effects summary EDD was -0.053 (95% CI, -0.065 to -0.040), indicating that women were underenrolled by 5.3 percentage points. This disparity persisted across virtually all geographic regions, intervention types, and stroke types, apart from subarachnoid hemorrhage (0.117 [95% CI, 0.084 to 0.150]). When subarachnoid hemorrhage trials were excluded, the summary EDD was -0.067 (95% CI, -0.078 to -0.057). In the multivariable metaregression analysis, an upper age limit of 80 years as an eligibility criterion was associated with a 6-percentage point decrease in the enrollment of women.

Conclusions and Relevance

Further research is needed to understand the causes of the underenrollment of women in acute stroke trials. However, to maximize representation, investigators should avoid imposing age limits on enrollment.

Time Window for Ischemic Stroke First Mobilization Effectiveness: Protocol for an Investigator-Initiated Prospective Multicenter Randomized 3-Arm Clinical Trial

OBJECTIVE

The purpose of this study is to investigate the optimal time window for initiating mobilizing after acute ischemic stroke.

METHODS

The TIME Trial is a pragmatic, investigator-initiated, multi-center, randomized, 3-arm parallel group, clinical trial. This trial will be conducted in 57 general hospitals in mainland China affiliated with the China Stroke Databank Center and will enroll 6033 eligible patients with acute ischemic stroke. Participants will be randomly allocated to either (1) the very early mobilization group in which mobilization is initiated within 24 hours from stroke onset, (2) the early mobilization group in which mobilization begins between 24 and 72 hours poststroke, or (3) the late mobilization group in which mobilization is started after 72 hours poststroke. The mobilization protocol is otherwise standardized and identical for each comparison group. Mobilization is titrated by baseline mobility level and progress of patients throughout the intervention period. The primary outcome is death or disability assessed with the modified Rankin scale at 3 months poststroke. Secondary outcomes include impairment score of the National Institutes of Health Stroke Scale, dependence in activities of daily living as measured using the modified Barthel Index, cognitive ability assessed with the Mini-Mental State Examination, incidence of adverse events, hospital length of stay, and total medical costs.

IMPACT

The TIME Trial is designed to answer the question "when is the best time to start mobilization after stroke?" The effect of timing is isolated from the effect of type and dose of mobilization by otherwise applying a standard mobilization protocol across groups. The TIME Trial may, therefore, contribute to increasing the knowledge base regarding the optimal time window for initiating mobilization after acute ischemic stroke.

Early physical rehabilitation therapy between 24 and 48 h following acute ischemic stroke onset: a randomized controlled trial

PURPOSE

Early mobilization is believed to be helpful for patients with acute ischemic stroke. This study aimed to compare the difference between starting rehabilitation between 24 and 48 h and 72 and 96 h following the onset of ischemic stroke.

MATERIALS AND METHODS

This was a single-center, single-blind, randomized controlled trial. The early rehabilitation (ER) group started exercising between 24 and 48 h after stroke onset, which the standard rehabilitation (SR) group started exercising between 72 and 96 h. The two groups received sitting, standing, and repetitive body strength training respectively.

RESULTS

In this study, 110 patients were analyzed. Patients in the early rehabilitation group had more favorable outcomes (The modified Rankin scale score 0-2, ER group = 32 versus SR group = 20, adjusted odds ratio 2.27, 95% CI 1.05-4.87; p = 0.036) at 3-month follow-up. The simplified Fugl-Meyer assessment (FMA) scores for the lower extremity were influenced by the interaction effect (F = 7.24, p = 0.01). The post-hoc analysis revealed a difference in the lower extremity FMA score at one week after stroke (difference 2.30 (95% CI 0.65-3.96); p = 0.007).

CONCLUSIONS

Early physical rehabilitation training between 24 and 48 h may be beneficial and improve patients' lower extremity function within the first week.

CLINICAL TRIAL REGISTRATION UNIQUE IDENTIFIER

NCT02718534Implications for rehabilitationAcute ischemic stroke has a variety of symptoms, and acroparalysis is a major concern.Starting physical rehabilitation early can improve the prognosis of patients with ischemic stroke.Early rehabilitation is more conducive to the recovery of lower extremity motor function, but in the subsequent rehabilitation process, the upper extremity function should be paid more attention.

An Animal Trial on the Optimal Time and Intensity of Exercise after Stroke

INTRODUCTION

Although exercise is a safe, cost-effective, and therapeutic poststroke therapy, the proper time window and dosage of exercise are still unknown. We aim to determine the optimal combination of time window and intensity of exercise by assessing infarct volume, neurological recovery, and underlying mechanisms in middle cerebral artery occlusion rats.

METHODS

The study contains two parts: the time-window and the dosage experiments. The time-window experiment assessed the effects of moderate-intensity exercise that was initiated at 24, 48, 72, 96 h and the control. In the dosage experiment, moderate and another two intensity exercise groups (low, high) were assessed. Forced wheel running was the exercise technique used. Infarct volume and neurological function (modified neurological severity scores [mNSS]) were measured. Inflammatory cytokines, cell death, and proliferation were further detected in the ischemic penumbra.

RESULTS

The time window part revealed that neither infarct volume nor mNSS was reduced in the exercise group initiated at 24 h. The other three groups with exercise initiated after 24 h had reduced infarct volume and reduced mNSS but those outcomes do not differ from each other. In the dosage part, the low- and moderate-intensity groups with exercise initiated at 48 h were both better than the high-intensity group in terms of infarct volume and mNSS at 14 d; however, there was no statistical difference between these low and moderate groups. Exercise initiated at 24 h or high-intensity promoted proinflammatory cytokines and cell death.

CONCLUSIONS

Exercise at 24 h is harmful. Low- and moderate-intensity exercise initiated at 48 h poststroke appears to be the optimal combination for maximal functional recovery.

Comorbidities associated with different levels of total cholesterol in male and female acute ischemic stroke patients

Men and women differ in their clinical risk factors with respect to various predictors of severity in acute ischemic stroke (AIS). High cholesterol is a risk factor for AIS and the mechanism by which high cholesterol levels lead to an AIS is well established. However, the specific relationship between demographic, clinical risk factors, total cholesterol, and the resulting gender difference in AIS patients is yet to be investigated. This study recruited AIS patients between January 2000 and June 2016 classified into normal, borderline or high total cholesterol (TC). Normal was defined as ≤200 mg/dl, borderline 200 to 239 mg/dl and high ≥240 mg/dl based on Adult Treatment Panel III (ATP III) Guidelines for the classification of TC levels. The logistic regression model was used to predict clinical risk factors associated within men and women AIS patients with different levels of TC. A total of 3532 AIS patients presented with normal TC, 760 patients with borderline TC and 427 patients with high TC. The high total cholesterol group was more likely to be women with increasing age (OR = 1.028, 95% CI, 1.006-1.052, P = .014), body mass index (BMI) (OR = 1.052, 95% CI, 1.004-1.102, P = .033), and high-density lipoprotein cholesterol (HDL-C) (OR = 1.039, 95% CI, 1.019-1.060, P < .001), while those with coronary artery disease (OR = 0.435, 95% CI, 0.234-0.809, P = .003), history of drug or alcohol abuse (OR = 0.261, 95% CI, 0.079-0.867, P = .028), increasing INR (OR = 0.187, 95% CI, 0.047-0.748, P = .018), and elevated diastolic blood pressure (OR = 0.982, 95% CI, 0.970-0.995, P = .006) were associated with being a male AIS patient. There were disparities in demographic and clinical risk factors associated with high TC levels in men when compared to women and more clinical risk factors were associated with high TC levels in men when compared to women with AIS. It is important to take into account specific clinical risk factors associated with gender-related differences in total cholesterol in AIS population to facilitate personalizing their therapeutic actions.

Elevated Urinary Titin and its Associated Clinical Outcomes after Acute Stroke

INTRODUCTION

Urinary titin is a biomarker of muscle atrophy, which is a serious complication after stroke. However, there are currently no clinical data regarding urinary titin in stroke patients.

METHODS

Consecutive stroke patients admitted to the stroke care unit were included. Spot urine samples were collected immediately after admission, and on days 3, 5, and 7. The primary outcome was the trend of urinary titin in patients after acute stroke. The secondary outcomes included the association between the peak urinary titin level and the modified Rankin Scale (mRS) score, the National Institutes of Health Stroke Scale (NIHSS) score, and the Barthel index (BI) upon hospital discharge. Multivariate analysis was adjusted for age, sex, NIHSS at admission, and the peak urinary titin to predict poor outcome (mRS 3-6).

RESULTS

Forty-one patients were included (29 male; age, 68 ± 15 years), 29 had ischemic stroke, 8 had intracerebral hemorrhage, and 4 had subarachnoid hemorrhage. The levels of urinary titin on days 1, 3, 5, and 7 were 9.9 (4.7-21.1), 16.2 (8.6-22.0), 8.9 (4.8-15.2), and 8.7 (3.6-16.2) pmol/mg Cr, respectively. The peak urinary titin level was associated with the mRS score (r = 0.55, p < 0.01), the NIHSS score (r = 0.72, p < 0.01), and the BI (r = -0.59, p < 0.01) upon hospital discharge. In multivariate analysis, the peak urinary titin was associated with poor outcome (p = 0.03).

CONCLUSIONS

Urinary titin rapidly increased after stroke and was associated with impaired functional outcomes at hospital discharge.

Effectiveness of patient education in acute stroke: a comparison between a customised computer system and a pictorial information booklet

Background

Patients who develop acute stroke are at high risk for deterioration in the first 48–72 hours after admission. An effective educational intervention is needed.

Objective

This study aimed to examine the applicability of the customised interactive computer education system (CICS) in patients who had a stroke in the early acute phase in order to determine the efficacy of the education system in (1) information satisfaction and (2) physiological related management compliance.

Methods

The prospective non-blinded randomised controlled study was conducted in an acute stroke unit of a local hospital in Hong Kong from March to August 2019. Chinese participants were selected if they were at least 18 years of age, experienced a minor stroke within 3 days. The exclusion criteria were communication problem and comorbidity with another acute disease. On the first day of admission, participants were allocated to the CICS and booklet groups, with each group comprising 50 participants. On the third day, the primary outcome, Modified Information Satisfaction Questionnaire for Acute Stroke (MISQ-S), was assessed.

Results

There was a significant difference in ‘the need to improve information measures’ of the MISQ-S (p=0.04) between the CICS and booklet groups. The management compliance of these two groups did not have difference, but the CICS group had better clinical outcome, though not significant (p=0.387).

Conclusion

Patient education was needed and feasible in the early acute phase, and the CICS was more efficacious than the booklet. The positive results provided insights into and give a direction to the use of information technology in patient education.

Role of Treatment Theory and Enablement Theory for Restoring Health and Rehabilitation in Saudi Arabia

Several challenges are involved in providing the appropriate treatment during the process of a patient's rehabilitation. Studies conducted in relation to the rehabilitation issues are ineffective in providing useful developments in the provided treatments. Most of the studies lack the utilization of theoretical framework which ultimately proposed weak findings. This study aimed to provide a theoretical framework in relation to the treatment theory as well as the enablement theory along with their effectiveness in improving rehabilitation treatments. The study involves a thorough review undertaking of published articles from 2014 to 2019 that were based on the rehabilitation and other health restoration measures through PubMed and Medline databases. Findings of the study were proposed in the form of a theoretical framework of treatment and the enablement theory. For rehabilitation and clinical researches, it is recommended to use treatment theory and enablement theory to propose unique results that may contribute to the improved healthcare treatment.

Physical exercise promotes astrocyte coverage of microvessels in a model of chronic cerebral hypoperfusion

BACKGROUND

Brain circulation disorders such as chronic cerebral hypoperfusion have been associated with a decline in cognitive function during the development of dementia. Astrocytes together with microglia participate in the immune response in the CNS and make them potential sentinels in the brain parenchyma. In addition, astrocytes coverage integrity has been related to brain homeostasis. Currently, physical exercise has been proposed as an effective intervention to promote brain function improvement. However, the neuroprotective effects of early physical exercise on the astrocyte communication with the microcirculation and the microglial activation in a chronic cerebral hypoperfusion model are still unclear. The aim of this study was to investigate the impact of early intervention with physical exercise on cognition, brain microcirculatory, and inflammatory parameters in an experimental model of chronic cerebral hypoperfusion induced by permanent bilateral occlusion of the common carotid arteries (2VO).

METHODS

Wistar rats aged 12 weeks were randomly divided into four groups: Sham-sedentary group (Sham-Sed), Sham-exercised group (Sham-Ex), 2VO-sedentary group (2VO-Sed), and 2VO-exercised group (2VO-Ex). The early intervention with physical exercise started 3 days after 2VO or Sham surgery during 12 weeks. Then, the brain functional capillary density and endothelial-leukocyte interactions were evaluated by intravital microscopy; cognitive function was evaluated by open-field test; hippocampus postsynaptic density protein 95 and synaptophysin were evaluated by western blotting; astrocytic coverage of the capillaries, microglial activation, and structural capillary density were evaluated by immunohistochemistry.

RESULTS

Early moderate physical exercise was able to normalize functional capillary density and reduce leukocyte rolling in the brain of animals with chronic cerebral hypoperfusion. These effects were accompanied by restore synaptic protein and the improvement of cognitive function. In addition, early moderate exercise improves astrocytes coverage in blood vessels of the cerebral cortex and hippocampus, decreases microglial activation in the hippocampus, and improves structural capillaries in the hippocampus.

CONCLUSIONS

Microcirculatory and inflammatory changes in the brain appear to be involved in triggering a cognitive decline in animals with chronic cerebral ischemia. Therefore, early intervention with physical exercise may represent a preventive approach to neurodegeneration caused by chronic cerebral hypoperfusion.

Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Community Participation following Stroke. Part One: Rehabilitation and Recovery Following Stroke; 6th Edition Update 2019

The sixth update of the Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Reintegration following Stroke. Part one: Rehabilitation and Recovery Following Stroke is a comprehensive set of evidence-based guidelines addressing issues surrounding impairments, activity limitations, and participation restrictions following stroke. Rehabilitation is a critical component of recovery, essential for helping patients to regain lost skills, relearn tasks, and regain independence. Following a stroke, many people typically require rehabilitation for persisting deficits related to hemiparesis, upper-limb dysfunction, pain, impaired balance, swallowing, and vision, neglect, and limitations with mobility, activities of daily living, and communication. This module addresses interventions related to these issues as well as the structure in which they are provided, since rehabilitation can be provided on an inpatient, outpatient, or community basis. These guidelines also recognize that rehabilitation needs of people with stroke may change over time and therefore intermittent reassessment is important. Recommendations are appropriate for use by all healthcare providers and system planners who organize and provide care to patients following stroke across a broad range of settings. Unlike the previous set of recommendations, in which pediatric stroke was included, this set of recommendations includes primarily adult rehabilitation, recognizing many of these therapies may be applicable in children. Recommendations related to community reintegration, which were previously included within this rehabilitation module, can now be found in the companion module, Rehabilitation, Recovery, and Community Participation following Stroke. Part Two: Transitions and Community Participation Following Stroke.

Cultural and linguistic adaptation of the Oxford Cognitive Screen to the Spanish population

INTRODUCTION

Stroke is the sixth leading cause of disability in Spain. Patients may present motor, sensory, or cognitive sequelae, which can be minimised with early treatment. To this end, there is a need for quick-to-administer assessment tools to evaluate deficits in these areas. The Oxford Cognitive Screen (OCS) is a brief test specifically designed to assess cognitive function in patients with stroke. Our aim in this study is to report the linguistic and cultural adaptation of a Spanish-language version of the test (OCS-S).

MATERIAL AND METHODS

The linguistic validation was conducted with a process of double translation and 10 consensus meetings of the multidisciplinary research team. We also performed 3 pilot studies, with 5 potential users, 23 healthy individuals, and 23 patients with stroke (ischaemic in 61% of cases and haemorrhagic in 39%), respectively; participants were aged between 31 and 88 years.

RESULTS

The OCS-S includes the 10 subtests, the coding of responses, and the scoring system from the original version. We modified and extended the instructions for administration in order to ensure the reliability of the content and its application. Five tasks were modified (images, numbers, and sentences) and the praxis subtest was modified to evaluate both hands. The pilot studies confirmed comprehension in the target population, independently of any cognitive problems.

CONCLUSIONS

The OCS-S is conceptually and linguistically equivalent to the original test, enabling psychometric assessment and application of the test in the Spanish population. The OCS-S may be a useful screening tool for quickly assessing cognitive function after stroke.

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.

Early Mobilization of Mild-Moderate Intracerebral Hemorrhage Patients in a Stroke Center: A Randomized Controlled Trial

Background. Few studies have addressed early out-of-bed mobilization specifically in acute intracerebral hemorrhage (ICH) patients. Patient benefit in such cases is unclear, with early intervention timing and duration identical to those in standard care. Objective. We investigated the efficacy of an early mobilization (EM) protocol, administered within 24 to 72 hours of stroke onset, for early functional independence in mild-moderate ICH patients. Methods. Sixty patients admitted to a stroke center within 24 hours of ICH were randomly assigned to early mobilization (EM) or standard early rehabilitation (SER). The EM group underwent an early out-of-bed mobilization protocol, while the SER group underwent a standard protocol focusing on in-bed training in the stroke center. Intervention in both groups lasted 30 minutes per session, once a day, 5 days a week. Motor subscales of the Functional Independence Measure (FIM-motor; primary outcome), Postural Assessment Scale for Stroke Patients, and Functional Ambulation Category (FAC) were evaluated (assessor-blinded) at baseline, and at 2 weeks, 4 weeks, and 3 months after stroke. Length of stay in the stroke center was also recorded. Results. The EM group showed significant improvement in FIM-motor score at all evaluated time points (P = .004) and in FAC outcomes at 2 weeks (P = .033) and 4 weeks (P = .011) after stroke. Length of stay in the stroke center was significantly shorter for the EM group (P = .004). Conclusion. Early out-of-bed mobilization via rehabilitation in a stroke center, within 24 to 72 hours of ICH, may improve early functional independence compared with standard early rehabilitation. Clinical Trial Registration: NCT03292211.

Aerobic Training and Mobilization Early Post-stroke: Cautions and Considerations

Knowledge gaps exist in how we implement aerobic exercise programs during the early phases post-stroke. Therefore, the objective of this review was to provide evidence-based guidelines for pre-participation screening, mobilization, and aerobic exercise training in the hyper-acute and acute phases post-stroke. In reviewing the literature to determine safe timelines of when to initiate exercise and mobilization we considered the following factors: arterial blood pressure dysregulation, cardiac complications, blood-brain barrier disruption, hemorrhagic stroke transformation, and ischemic penumbra viability. These stroke-related impairments could intensify with inappropriate mobilization/aerobic exercise, hence we deemed the integrity of cerebral autoregulation to be an essential physiological consideration to protect the brain when progressing exercise intensity. Pre-participation screening criteria are proposed and countermeasures to protect the brain from potentially adverse circulatory effects before, during, and following mobilization/exercise sessions are introduced. For example, prolonged periods of standing and static postures before and after mobilization/aerobic exercise may elicit blood pooling and/or trigger coagulation cascades and/or cerebral hypoperfusion. Countermeasures such as avoiding prolonged standing or incorporating periodic lower limb movement to activate the venous muscle pump could counteract blood pooling after an exercise session, minimize activation of the coagulation cascade, and mitigate potential cerebral hypoperfusion. We discuss patient safety in light of the complex nature of stroke presentations (i.e., type, severity, and etiology), medical history, comorbidities such as diabetes, cardiac manifestations, medications, and complications such as anemia and dehydration. The guidelines are easily incorporated into the care model, are low-risk, and use minimal resources. These and other strategies represent opportunities for improving the safety of the activity regimen offered to those in the early phases post-stroke. The timeline for initiating and progressing exercise/mobilization parameters are contingent on recovery stages both from neurobiological and cardiovascular perspectives, which to this point have not been specifically considered in practice. This review includes tailored exercise and mobilization prescription strategies and precautions that are not resource intensive and prioritize safety in stroke recovery.

Functional recovery differences after stroke rehabilitation in patients with uni- or bilateral hemiparesis

OBJECTIVE

To examine the functional recovery differences after stroke rehabilitation in patients with uni- or bilateral hemiparesis.

METHODS

In this retrospective study, we included data from the medical record of all 383 patients with uni- or bilateral hemiparesis after stroke who were admitted to King Fahad Medical City-Rehabilitation Hospital between 2008 and 2014 in Riyadh, Kingdom of Saudi Arabia. According to the site of hemiparesis, we classified patients into 3 groups: right hemiparesis (n=208), left hemiparesis (n=157), and bilateral hemipareses (n=18). The patients (n=49) who did not have either site of hemiparesis were excluded. The Functional Independence Measures (FIM) instrument was used to assess the score at admission and discharge. A post hoc test was conducted to examine the functional recovery differences between groups. Multiple regression analyses were used to confirm the findings.

RESULTS

Amongst the three groups, there were significant (p<0.05) differences in the total-FIM score as well as motor- and cognitive-FIM sub-scores between admission and discharge of stroke rehabilitation. The differences were significantly greater in the bilateral hemipareses group than in either unilateral hemiparesis group. Multiple regression analyses also confirmed that the site of hemiparesis significantly (p<0.05) differs in the total-FIM score as well as motor-FIM and cognitive-FIM sub-scores.

CONCLUSION

Our results demonstrate that differences in functional recovery after stroke rehabilitation may be influenced by the site of hemiparesis after stroke.

Early Ambulation Among Hospitalized Heart Failure Patients Is Associated With Reduced Length of Stay and 30-Day Readmissions

BACKGROUND

Early ambulation (EA) is associated with improved outcomes for mechanically ventilated and stroke patients. Whether the same association exists for patients hospitalized with acute heart failure is unknown. We sought to determine whether EA among patients hospitalized with heart failure is associated with length of stay, discharge disposition, 30-day post discharge readmissions, and mortality.

METHODS AND RESULTS

The study population included 369 hospitals and 285 653 patients with heart failure enrolled in the Get With The Guidelines-Heart Failure registry. We used multivariate logistic regression with generalized estimating equations at the hospital level to identify predictors of EA and determine the association between EA and outcomes. Sixty-five percent of patients ambulated by day 2 of the hospital admission. Patient-level predictors of EA included younger age, male sex, and hospitalization outside of the Northeast (P<0.01 for all). Hospital size and academic status were not predictive. Hospital-level analysis revealed that those hospitals with EA rates in the top 25% were less likely to have a long length of stay (defined as >4 days) compared with those in the bottom 25% (odds ratio, 0.83; confidence interval, 0.73-0.94; P=0.004). Among a subgroup of fee-for-service Medicare beneficiaries, we found that hospitals in the highest quartile of rates of EA demonstrated a statistically significant 24% lower 30-day readmission rates (P<0.0001). Both end points demonstrated a dose-response association and statistically significant P for trend test.

CONCLUSIONS

Multivariable-adjusted hospital-level analysis suggests an association between EA and both shorter length of stay and lower 30-day readmissions. Further prospective studies are needed to validate these findings.

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.

Time spent lying, sitting, and upright during hospitalization after stroke: a prospective observation study

Background

Early mobilization has been an important part of acute stroke unit treatment. However, early and intense mobilization within the first 24 h post stroke may cause an unfavorable outcome. Recently, objective measurements using body-worn sensors have been applied, enabling continuous monitoring of physical activity in the hospital setting. This study aimed to use body-worn sensors to quantify the amount of physical activity and how activity levels changed over time during hospitalization in patients with acute stroke. We also wanted to investigate which factors were associated with upright and sitting activity.

Methods

This was a prospective study including patients admitted to hospital within seven days after onset of stroke. Physical activity was measured by two sensors (ActivPALs from PAL Technologies Ltd., Glasgow, UK), one attached on sternum and one on the thigh of the unaffected side, monitoring continuously from inclusion until discharge. Data were processed in Matlab R 2015B and provided information about daily time in lying, sitting, and upright positions, and daily average duration of sitting and upright bouts. A linear mixed model was used to analyze changes over time.

Results

58 patients were included (31 women, mean (SD) age; 75.1 (12.0)). Patients were hospitalized for 12.1 (7.6) days and had a mean score on the National Institute of Health Stroke Scale of 6.2 (5.5) points. Time spent sitting and time spent upright increased per day during hospitalization by 22.10 min (95% Confidence interval (CI): 14.96, 29.24) and 3.75 min (95% CI: 1.70, 5.80) respectively. Increased time upright was associated with improved Modified Rankin Scale scores (− 38.09 min, 95% CI: -61.88, − 14.29) and higher Short Physical Performance Battery scores (6.97 min, 95% CI: 1.99, 11.95), while prolonged bouts of sitting were associated with more severe stroke (4.50 min, 95% CI: 0.80, 8.19), and older age (1.72 min, 95% CI: 0.20, 3.26).

Conclusions

Patients increased their daily time spent sitting and upright during the initial hospital stay after stroke. Prolonged bouts of sitting were associated with older age and more severe strokes. Hence future research should investigate the benefit of interventions aimed at breaking up sitting time after stroke.

Cerebrolysin: a multi-target drug for recovery after stroke

INTRODUCTION

Cerebrolysin is a neuropeptide preparation with neurotrophic effects and promotes recovery after brain injury. Its preclinical profile promises wide applications due to its multi-target effects. Currently, Cerebrolysin is used for treatment of cerebral ischemia and neurodegeneration. Areas covered: In stroke, earlier clinical trials with Cerebrolysin were performed mostly in mildly affected stroke populations, which usually have a favorable prognosis. Due to this selection, a floor or ceiling effect of recovery measures in the mild cases may have prevented to show a clear benefit between treatment groups. In contrast, subgroup analyses of more severely affected patients reveal a strikingly positive effect for enhanced recovery. Based on the findings from several studies, it became evident that the effect size of Cerebrolysin was increasing with stroke severity. Other controlled studies showed that Cerebrolysin can be safely used in combination with thrombolysis. More recently, Cerebrolysin has been tested not only for neuroprotection but also for its neurorecovery potential and also showed efficacy in patients with moderate to severe strokes. Expert commentary: Cerebrolysin shows a benefit mostly in moderate to severe ischemic stroke patients and an overall significant effect for functional recovery when combined with neurorehabilitation versus neurorehabilitation alone. This gives lead to the planning of a more rigorous study design in the future.

A Very Early Rehabilitation Trial after stroke (AVERT): a Phase III, multicentre, randomised controlled trial

BACKGROUND

Mobilising patients early after stroke [early mobilisation (EM)] is thought to contribute to the beneficial effects of stroke unit care but it is poorly defined and lacks direct evidence of benefit.

OBJECTIVES

We assessed the effectiveness of frequent higher dose very early mobilisation (VEM) after stroke.

DESIGN

We conducted a parallel-group, single-blind, prospective randomised controlled trial with blinded end-point assessment using a web-based computer-generated stratified randomisation.

SETTING

The trial took place in 56 acute stroke units in five countries.

PARTICIPANTS

We included adult patients with a first or recurrent stroke who met physiological inclusion criteria.

INTERVENTIONS

Patients received either usual stroke unit care (UC) or UC plus VEM commencing within 24 hours of stroke.

MAIN OUTCOME MEASURES

The primary outcome was good recovery [modified Rankin scale (mRS) score of 0-2] 3 months after stroke. Secondary outcomes at 3 months were the mRS, time to achieve walking 50 m, serious adverse events, quality of life (QoL) and costs at 12 months. Tertiary outcomes included a dose-response analysis.

DATA SOURCES

Patients, outcome assessors and investigators involved in the trial were blinded to treatment allocation.

RESULTS

We recruited 2104 (UK, n = 610; Australasia, n = 1494) patients: 1054 allocated to VEM and 1050 to UC. Intervention protocol targets were achieved. Compared with UC, VEM patients mobilised 4.8 hours [95% confidence interval (CI) 4.1 to 5.7 hours; p < 0.0001] earlier, with an additional three (95% CI 3.0 to 3.5; p < 0.0001) mobilisation sessions per day. Fewer patients in the VEM group (n = 480, 46%) had a favourable outcome than in the UC group (n = 525, 50%) (adjusted odds ratio 0.73, 95% CI 0.59 to 0.90; p = 0.004). Results were consistent between Australasian and UK settings. There were no statistically significant differences in secondary outcomes at 3 months and QoL at 12 months. Dose-response analysis found a consistent pattern of an improved odds of efficacy and safety outcomes in association with increased daily frequency of out-of-bed sessions but a reduced odds with an increased amount of mobilisation (minutes per day).

LIMITATIONS

UC clinicians started mobilisation earlier each year altering the context of the trial. Other potential confounding factors included staff patient interaction.

CONCLUSIONS

Patients in the VEM group were mobilised earlier and with a higher dose of therapy than those in the UC group, which was already early. This VEM protocol was associated with reduced odds of favourable outcome at 3 months cautioning against very early high-dose mobilisation. At 12 months, health-related QoL was similar regardless of group. Shorter, more frequent mobilisation early after stroke may be associated with a more favourable outcome.

FUTURE WORK

These results informed a new trial proposal [A Very Early Rehabilitation Trial - DOSE (AVERT-DOSE)] aiming to determine the optimal frequency and dose of EM.

TRIAL REGISTRATION

The trial is registered with the Australian New Zealand Clinical Trials Registry number ACTRN12606000185561, Current Controlled Trials ISRCTN98129255 and ISRCTN98129255.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 54. See the NIHR Journals Library website for further project information. Funding was also received from the National Health and Medical Research Council Australia, Singapore Health, Chest Heart and Stroke Scotland, Northern Ireland Chest Heart and Stroke, and the Stroke Association. In addition, National Health and Medical Research Council fellowship funding was provided to Julie Bernhardt (1058635), who also received fellowship funding from the Australia Research Council (0991086) and the National Heart Foundation (G04M1571). The Florey Institute of Neuroscience and Mental Health, which hosted the trial, acknowledges the support received from the Victorian Government via the Operational Infrastructure Support Scheme.

Effect of accelerometer-based feedback on physical activity in hospitalized patients with ischemic stroke: a randomized controlled trial

Objective:

To evaluate the effect of accelerometer-based feedback on physical activity in hospitalized patients with ischemic stroke.

Design:

Randomized controlled trial.

Setting:

Acute care hospital.

Subjects:

A total of 55 patients with ischemic stroke who could walk without assistance were randomly assigned to the intervention group ( n = 27) or the control group ( n = 28).

Interventions:

At the baseline measurement, patients did not receive accelerometer-based feedback. At follow-up, a physical therapist provided instruction on accelerometer-based feedback, discussed physical activity targets and encouraged the patients to walk more until discharge.

Main measures:

The average daily number of steps taken was used as the index of daily hospitalized physical activity.

Results:

The study sample consisted of 48 patients, of whom 23 patients comprised the intervention group and 25 patients comprised the control group. Although there were no significant differences in physical activity values between the two groups at the baseline measurement, the values in the intervention group at follow-up were significantly higher than those in the control group (5180.5 ± 2314.9 vs. 3113.6 ± 1150.9 steps/day, P = 0.0003). The effect size of physical activity values (Cohen’s d = 1.15) at follow-up was large between the two groups.

Conclusion:

Exercise training combined with accelerometer-based feedback effectively increased physical activity in hospitalized patients with ischemic stroke.

Early Rehabilitation After Stroke: a Narrative Review

PURPOSE OF REVIEW

Despite current rehabilitative strategies, stroke remains a leading cause of disability in the USA. There is a window of enhanced neuroplasticity early after stroke, during which the brain's dynamic response to injury is heightened and rehabilitation might be particularly effective. This review summarizes the evidence of the existence of this plastic window, and the evidence regarding safety and efficacy of early rehabilitative strategies for several stroke domain-specific deficits.

RECENT FINDINGS

Overall, trials of rehabilitation in the first 2 weeks after stroke are scarce. In the realm of very early mobilization, one large and one small trial found potential harm from mobilizing patients within the first 24 h after stroke, and only one small trial found benefit in doing so. For the upper extremity, constraint-induced movement therapy appears to have benefit when started within 2 weeks of stroke. Evidence for non-invasive brain stimulation in the acute period remains scant and inconclusive. For aphasia, the evidence is mixed, but intensive early therapy might be of benefit for patients with severe aphasia. Mirror therapy begun early after stroke shows promise for the alleviation of neglect. Novel approaches to treating dysphagia early after stroke appear promising, but the high rate of spontaneous improvement makes their benefit difficult to gauge. The optimal time to begin rehabilitation after a stroke remains unsettled, though the evidence is mounting that for at least some deficits, initiation of rehabilitative strategies within the first 2 weeks of stroke is beneficial. Commencing intensive therapy in the first 24 h may be harmful.

Deep brain stimulation for stroke: Current uses and future directions

BACKGROUND

Survivors of stroke often experience significant disability and impaired quality of life related to ongoing maladaptive responses and persistent neurologic deficits. Novel therapeutic options are urgently needed to augment current approaches. One way to promote recovery and ameliorate symptoms may be to electrically stimulate the surviving brain. Various forms of brain stimulation have been investigated for use in stroke, including deep brain stimulation (DBS).

OBJECTIVE/METHODS

We conducted a comprehensive literature review in order to 1) review the use of DBS to treat post-stroke maladaptive responses including pain, dystonia, dyskinesias, and tremor and 2) assess the use and potential utility of DBS for enhancing plasticity and recovery from post-stroke neurologic deficits.

RESULTS/CONCLUSIONS

A large variety of brain structures have been targeted in post-stroke patients, including motor thalamus, sensory thalamus, basal ganglia nuclei, internal capsule, and periventricular/periaqueductal grey. Overall, the reviewed clinical literature suggests a role for DBS in the management of several post-stroke maladaptive responses. More limited evidence was identified regarding DBS for post-stroke motor deficits, although existing work tentatively suggests DBS-particularly DBS targeting the posterior limb of the internal capsule-may improve paresis in certain circumstances. Substantial future work is required both to establish optimal targets and parameters for treatment of maladapative responses and to further investigate the effectiveness of DBS for post-stroke paresis.

Efficacy and Safety of Very Early Mobilization in Patients with Acute Stroke: A Systematic Review and Meta-analysis

Whether very early mobilization (VEM) improves outcomes in stroke patients and reduces immobilization-related complications (IRCs) is currently unknown. The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of VEM in acute stroke patients following admission. Medline, Embase, and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials (RCTs) that examined the efficacy or safety of VEM in patients with acute stroke. VEM was defined as out of bed activity commencing within 24 or 48 hours after the onset of stroke. A total of 9 RCTs with 2,803 participants were included. Upon analysis, VEM was not associated with favorable functional outcomes (modified Ranking Scale: 0–2) at 3 months [relative risk (RR): 0.96; 95% confidence interval (CI): 0.86–1.06]; VEM did not reduce the risk of IRCs during follow up. With respect to safety outcomes, VEM was not associated with a higher risk of death (RR: 1.04; 95% CI: 0.52–2.09) and did not increase the risk of neurological deterioration or incidence of falls with injury. In conclusion, pooled data from RCTs concluded that VEM is not associated with beneficial effects when carried out in patients 24 or 48 hours after the onset of a stroke.

Stroke rehabilitation. A call to action in Saudi Arabia

Stroke is a major cause of death and other complications worldwide. In Saudi Arabia, stroke has become an emerging health issue leading to disability and death. However, stroke care including rehabilitation services, in Saudi Arabia lags behind developed countries. Stroke rehabilitation is an essential recovery option after stroke and should start as early as possible to avoid potential complications. The growing evidence on stroke rehabilitation effectiveness in different health care settings and outcome measures used widely are reviewed in this call to action paper.

Access, timing and frequency of very early stroke rehabilitation - insights from the Baden-Wuerttemberg stroke registry

BACKGROUND

While the precise timing and intensity of very early rehabilitation (VER) after stroke onset is still under discussion, its beneficial effect on functional disability is generally accepted. The recently published randomized controlled AVERT trial indicated that patients with severe stroke might be more susceptible to harmful side effects of VER, which we hypothesized is contrary to current clinical practice. We analyzed the Baden-Wuerttemberg stroke registry to gain insight into the application of VER in acute ischemic stroke (IS) and intracerebral hemorrhage (ICH) in clinical practice.

METHODS

99,753 IS patients and 8824 patients with ICH hospitalized from January 2008 to December 2012 were analyzed. Data on the access to physical therapy (PT), occupational therapy (OT), and speech therapy (ST), the time from admission to first contact with a therapist and the average number of therapy sessions during the first 7 days of admission are reported. Multiple logistic regression models adjusted for patient and treatment characteristics were carried out to investigate the influence of VER on clinical outcome.

RESULTS

PT was applied in 90/87% (IS/ICH), OT in 63/57%, and ST in 70/65% of the study population. Therapy was mostly initiated within 24 h (PT 87/82%) or 48 h after admission (OT 91/89% and ST 93/90%). Percentages of patients under therapy and also the average number of therapy sessions were highest in those with a discharge modified Rankin Scale score of 2 to 5 and lowest in patients with complete recovery or death during hospitalization. The outcome analyses were fundamentally hindered due to biases by individual decision making regarding the application and frequency of VER.

CONCLUSIONS

While most patients had access to PT we noticed an undersupply of OT and ST. Only little differences were observed between patients with IS and ICH. The staff decisions for treatment seem to reflect attempts to optimize resources. Patients with either excellent or very unfavorable prognosis were less frequently assigned to VER and, if treated, received a lower average number of therapy sessions. On the contrary, severely disabled patients received VER at high frequency, although potentially harmful according to recent indications from the randomized controlled AVERT trial.

Early Mobilization after Stroke: Changes in Clinical Opinion Despite an Unchanging Evidence Base

BACKGROUND

We sought to determine whether Australasian health professionals' opinions regarding early mobilization after stroke changed between 2008 and 2014, when a large international trial of early mobilization (A Very Early Rehabilitation Trial, AVERT) was underway.

METHODS

Attendees at the two major Australasian stroke conferences in 2008 and 2014 were surveyed. Participants rated their agreement with statements about the risks and benefits of commencing mobilization within 24 hours of hemorrhagic and ischemic stroke using a 5-point Likert scale. Participants in 2014 were asked about their awareness of AVERT. Logistic regressions were performed to determine whether the time point (2008 versus 2014) or awareness of AVERT influenced opinions about early mobilization.

RESULTS

Surveys were completed by 443 health professionals (2008: N = 202; 2014: N = 241). Most respondents in 2014 reported that early mobilization was beneficial and not harmful to people with ischemic and hemorrhagic stroke. Opinions regarding mobilization after ischemic stroke did not change significantly between 2008 and 2014. In 2014, a significantly greater proportion of respondents believed that early mobilization after hemorrhagic stroke was helpful (2008: n = 98 of 202 [49%] versus 2014: n = 170 of 241 [71%], P < .01). Awareness of AVERT was significantly associated with the opinion that early mobilization was beneficial and not harmful to patients with stroke (P < .05).

CONCLUSIONS

Australasian health professionals' opinions of early mobilization after hemorrhagic stroke changed between 2008 and 2014, prior to reporting of the AVERT trial. Our results suggest that awareness of an ongoing research trial can lead to changes in opinions before the efficacy of the experimental intervention is known.

Serial NIHSS scores in patients with acute cerebral infarction

AIM

To study time course of neurological deficits in patients with acute cerebral infarction admitted shortly after stroke onset.

METHODS

Serial NIHSS scores were obtained whenever feasible in patients admitted because of cerebral infarction within 3 h of symptom onset. Patients receiving and not receiving thrombolysis were compared. Short-term outcome was defined as NIHSS score and modified Rankin score 7 days after stroke onset. The hyperacute phase was defined as the time between stroke onset and the 6- to 9-h interval after stroke onset, acute phase as the time between the 6- to 9-h interval and the 21 to 27-h interval, and the subacute phase as the time between the 21- to 27-h interval and 7 days after stroke onset.

RESULTS

Serial NIHSS scores were obtained in 552 patients within three hours of stroke onset. There was a significant improvement (P < 0.001) comprising 62% of the total improvement in the hyperacute phase. There was no significant improvement in the acute phase and a small significant improvement in the subacute phase (P < 0.01).

CONCLUSION

Our study demonstrates a hyperacute phase with rapid improvement probably due to early recanalization, an acute phase with no significant improvement and slow improvement in the subacute phase. Different pathophysiological mechanisms are likely involved in the different phases.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Early Sitting in Ischemic Stroke Patients (SEVEL): A Randomized Controlled Trial

BACKGROUND

Extended immobility has been associated with medical complications during hospitalization. However no clear recommendations are available for mobilization of ischemic stroke patients.

OBJECTIVE

As early mobilization has been shown to be feasible and safe, we tested the hypothesis that early sitting could be beneficial to stroke patient outcome.

METHODS

This prospective multicenter study tested two sitting procedures at the acute phase of ischemic stroke, in a randomized controlled fashion (clinicaltrials.org registration number NCT01573299). Patients were eligible if they were above 18 years of age and showed no sign of massive infarction or any contra-indication for sitting. In the early-sitting group, patients were seated out of bed at the earliest possible time but no later than one calendar day after stroke onset, whereas the progressively-sitting group was first seated out of bed on the third calendar day after stroke onset. Primary outcome measure was the proportion of patients with a modified Rankin score [0-2] at 3 months post stroke. Secondary outcome measures were a.) prevalence of medical complications, b.) length of hospital stay, and c.) tolerance to the procedure.

RESULTS

One hundred sixty seven patients were included in the study, of which 29 were excluded after randomization. Data from 138 patients, 63 in the early-sitting group and 75 in the progressively-sitting group were analyzed. There was no difference regarding outcome of people with stroke, with a proportion of Rankin [0-2] score at 3 months of 76.2% and 77.3% of patients in the early- and progressive-sitting groups, respectively (p = 0.52). There was also no difference between groups for secondary outcome measures, and the procedure was well tolerated in both arms.

CONCLUSION

Due to a slow enrollment, fewer patients than anticipated were available for analysis. As a result, we can only detect beneficial/detrimental effects of +/- 15% of the early sitting procedure on stroke outcome with a realized 37% power. However, enrollment was sufficient to rule out effect sizes greater than 25% with 80% power, indicating that early sitting is unlikely to have an extreme effect in either direction on stroke outcome. Additionally, we were not able to provide a blinded assessment of the primary outcome. Taking these limitations into account, our results may help guide the development of more effective acute stroke rehabilitation strategies, and the design of future acute stroke trials involving out of bed activities and other mobilization regimens.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01573299.

Cerebrolysin and Recovery After Stroke (CARS): A Randomized, Placebo-Controlled, Double-Blind, Multicenter Trial

Supplemental Digital Content is available in the text.

The aim of this trial was to investigate whether stroke patients who receive Cerebrolysin show improved motor function in the upper extremities at day 90 compared with patients who receive a placebo.

Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial

BACKGROUND

Early mobilisation after stroke is thought to contribute to the effects of stroke-unit care; however, the intervention is poorly defined and not underpinned by strong evidence. We aimed to compare the effectiveness of frequent, higher dose, very early mobilisation with usual care after stroke.

METHODS

We did this parallel-group, single-blind, randomised controlled trial at 56 acute stroke units in five countries. Patients (aged ≥18 years) with ischaemic or haemorrhagic stroke, first or recurrent, who met physiological criteria were randomly assigned (1:1), via a web-based computer generated block randomisation procedure (block size of six), to receive usual stroke-unit care alone or very early mobilisation in addition to usual care. Treatment with recombinant tissue plasminogen activator was allowed. Randomisation was stratified by study site and stroke severity. Patients, outcome assessors, and investigators involved in trial and data management were masked to treatment allocation. The primary outcome was a favourable outcome 3 months after stroke, defined as a modified Rankin Scale score of 0-2. We did analysis on an intention-to-treat basis. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12606000185561.

FINDINGS

Between July 18, 2006, and Oct 16, 2014, we randomly assigned 2104 patients to receive either very early mobilisation (n=1054) or usual care (n=1050); 2083 (99%) patients were included in the 3 month follow-up assessment. 965 (92%) patients were mobilised within 24 h in the very early mobilisation group compared with 623 (59%) patients in the usual care group. Fewer patients in the very early mobilisation group had a favourable outcome than those in the usual care group (n=480 [46%] vs n=525 [50%]; adjusted odds ratio [OR] 0·73, 95% CI 0·59-0·90; p=0·004). 88 (8%) patients died in the very early mobilisation group compared with 72 (7%) patients in the usual care group (OR 1·34, 95% CI 0·93-1·93, p=0·113). 201 (19%) patients in the very early mobilisation group and 208 (20%) of those in the usual care group had a non-fatal serious adverse event, with no reduction in immobility-related complications with very early mobilisation.

INTERPRETATION

First mobilisation took place within 24 h for most patients in this trial. The higher dose, very early mobilisation protocol was associated with a reduction in the odds of a favourable outcome at 3 months. Early mobilisation after stroke is recommended in many clinical practice guidelines worldwide, and our findings should affect clinical practice by refining present guidelines; however, clinical recommendations should be informed by future analyses of dose-response associations.

FUNDING

National Health and Medical Research Council, Singapore Health, Chest Heart and Stroke Scotland, Northern Ireland Chest Heart and Stroke, UK Stroke Association, National Institute of Health Research.