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Early mobilization after stroke onset does not improve recovery

Early mobilization after stroke onset does not improve recovery

Very early mobilization(VEM) within 24 hours of stroke onset, did not increase the number of people who survived or made a good recovery after their stroke, according to a systematic review and meta-analysis published in Cochrane Review.

Care in a stroke unit is recommended for people soon after a stroke and results in an improved chance of surviving and returning home. Very early mobilization (helping people to get up out of bed very early, and more often after the onset of stroke symptoms) is performed in some stroke unit and is recommended in many acute stroke clinical guidelines. However, the impact of very early mobilization on recovery after stroke is not clear.

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Peter Langhorne and his associates performed a systematic review to determine whether very early mobilization (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.

The investigators did the review of the existing literature which included 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 mobilization was commenced later. The investigators included nine RCTs with 2958 participants.

The primary outcome was death or poor outcome (dependency or institutionalization) at the end of scheduled follow‐up. Secondary outcomes included death, dependency, institutionalization, 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 analyzed outcomes at three‐month follow‐up.

The key study analysis included were:

  • The median (range) delay to starting mobilization after stroke onset was 18.5 hours in the VEM group and 33.3  hours in the usual care group. The median difference within trials was 12.7 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 mobilization activity.
  • Primary outcome data were available for 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 mobilization (51% versus 49%). The death occurred in 7% of participants who received delayed mobilization, and 8.5% of participants who received VEM), and the effects on experiencing any complication were unclear. Analysis using outcomes collected only at three‐month follow‐up did not alter the conclusions.

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  • The mean activities of daily living(ADL) score was higher in those who received VEM compared with the usual care group 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.
  • Low‐quality evidence indicated that time‐to‐first mobilization at around 24 hours was associated with the lowest odds of death or poor outcome, compared with earlier or later mobilization.

“We believe that the evidence supported a cautious approach to active mobilization within 24 hours of stroke onset because the single largest trial, and a sensitivity analysis of trials recruiting within 24 hours, raised the possibility that VEM commencing within 24 hours may carry some increased hazard,” write the authors.

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Source: With inputs from Cochrane

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