Very early versus delayed mobilisation after stroke

Bernhardt J, Thuy MNT, Collier JM, Legg LA

Published Online:

January 21, 2009

The impact of very early mobilisation on recovery after stroke is not clear. Care in a stroke unit is recommended for patients early after stroke and results in reduced disability and an increased likelihood of returning home. Very early mobilisation (helping patients to get up out of bed very early and often after stroke symptom onset) is performed in some stroke units and is recommended in many acute stroke clinical guidelines. However, this review identified only one small trial (71 participants) which found no difference in death and dependency at three months between those who undertook an early intensive mobilisation protocol and those who did not. No significant harms were identified and a small reduction in non serious adverse events was found. At present there is insufficient evidence to support or refute the effects of routine very early mobilisation after stroke and several trials are currently ongoing.

Abstract (click to read)

Background:

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

Objectives:

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

Search strategy:

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

Selection criteria:

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

Data collection and analysis:

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

Main results:

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

Authors' conclusions:

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

This record should be cited as:

Bernhardt J, Thuy MNT, Collier JM, Legg LA. Very early versus delayed mobilisation after stroke. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD006187. DOI: 10.1002/14651858.CD006187.pub2

Assessed as up to date:

May 5, 2008

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Primary Review Group:

Stroke Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective is very early mobilisation after stroke (commenced within 48 hours of stroke) compared to conventional care?

Bottom line:

There is insufficient evidence regarding the benefits or harms of very early mobilisation after stroke to make any recommendation on the practice. One small trial found no difference in death and dependency at 3 months between those who undertook an early intensive mobilisation protocol and those who did not. No significant harms were identified, and a small reduction in non-serious adverse events was found. No significant difference on any secondary outcome of interest was found (quality of life, patient mood, performance of activities of daily living, requirement for institutional care, or time to walking unassisted).

Caveat:

The review found only 1 small trial which met the inclusion criteria. Nineteen relevant trials from China failed to meet the inclusion criteria.

Context:

Care in a stroke unit is recommended for patients early after stroke and results in reduced disability and an increased likelihood of returning home. Very early mobilisation (helping patients to get up out of bed very early and often after stroke symptom onset) is undertaken in some stroke units and is recommended in many acute stroke clinical guidelines. It is unclear whether very early mobilisation independently improves outcome after stroke.

Cochrane Systematic Review:

Bernhardt J et al. Very early versus delayed mobilisation after stroke. Cochrane Reviews 2009, Issue 1. Article No. CD006187. DOI: 10.1002/14651858.CD006187.pub2. This review contains 1 study involving 71 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Heart & circulation > Stroke > Rehabilitation

Neurology > Stroke > Rehabilitation

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Very early versus delayed mobilisation after stroke

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