Early Mobilization After Stroke | Journal Scan
What is the effectiveness of frequent, higher-dose, very early mobilization as compared with usual care after stroke?
AVERT was a parallel-group, single-blind, randomized, controlled trial at 56 acute stroke units in five countries. Patients (aged ≥18 years) with ischemic or hemorrhagic stroke, first or recurrent, who met physiological criteria were randomly assigned (1:1), via a web-based computer-generated block randomization procedure (block size of six), to receive usual stroke-unit care alone or very early mobilization in addition to usual care. Treatment with recombinant tissue plasminogen activator was allowed. Randomization 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 favorable outcome 3 months after stroke, defined as a modified Rankin Scale score of 0–2. The investigators did analysis on an intention-to-treat basis.
The investigators randomly assigned 2,104 patients to receive either very early mobilization (n = 1,054) or usual care (n = 1,050) between July 18, 2006, and Oct 16, 2014; 2,083 (99%) patients were included in the 3-month follow-up assessment. A total of 965 (92%) patients were mobilized within 24 hours in the very early mobilization group compared with 623 (59%) patients in the usual care group. Fewer patients in the very early mobilization group had a favorable outcome than those in the usual care group (n = 480 [46%] vs. n = 525 [50%]; adjusted odds ratio [OR], 0.73; 95% confidence interval [CI], 0.59-0.90; p = 0.004). Eighty-eight (8%) patients died in the very early mobilization group compared with 72 (7%) patients in the usual care group (OR, 1.34; 95% CI, 0.93-1.93; p = 0.113). Two hundred and one (19%) patients in the very early mobilization group and 208 (20%) of those in the usual care group had a nonfatal serious adverse event, with no reduction in immobility-related complications with very early mobilization.
The authors concluded that a higher-dose, very early mobilization protocol was associated with a reduction in the odds of a favorable outcome at 3 months.
This study reports that very early mobilization was associated with a significant reduction in the odds of little or no disability at 3 months after stroke, with no evidence of accelerated recovery. Early mobilization after stroke is recommended in many clinical practice guidelines worldwide, and these findings challenge the current dogma that more is better and may not apply to the early post-stroke period. At this time, it seems prudent to practice early, lower-dose out-of-bed activity regimen compared to very early, frequent, higher-dose intervention; however, future clinical recommendations should be informed by additional prospective studies that assess dose–response of rehabilitation (rather than group) on efficacy and safety outcomes.
Keywords: Early Ambulation, Follow-Up Studies, Intention to Treat Analysis, Intracranial Hemorrhages, Mobility Limitation, Outcome Assessment (Health Care), Physical Therapy Modalities, Random Allocation, Secondary Prevention, Single-Blind Method, Rehabilitation, Stroke, Tissue Plasminogen Activator
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