Stroke. 2009;40:e489-e490
Published online before print June 4, 2009,
doi: 10.1161/STROKEAHA.109.549899
(Stroke. 2009;40:e489.)
© 2009 American Heart Association, Inc.
Very Early Versus Delayed Mobilization After Stroke
Julie Bernhardt, PhD;
Matthew N.T. Thuy, MBBS;
Janice M. Collier, PhD
Lynn A. Legg, MPH
From the Very Early Rehabilitation Research Program (J.B.), National Stroke Research Institute, Melbourne, Australia; the National Stroke Research Institute (M.N.T.T., J.M.C.), Melbourne, Australia; Research Fellow, and the Academic Section of Geriatric Medicine (L.A.L.), University of Glasgow, Glasgow, UK.
Correspondence to Julie Bernhardt, PhD, National Stroke Research Institute, Level 2, Neurosciences Building, Austin Health, 300 Waterdale Road, Melbourne, Australia 3081. E-mail j.bernhardt{at}unimelb.edu.au
Graeme J. Hankey MD, FRCP Section Editor:
Key Words: ambulation • cerebrovascular accident • early rehabilitation • exercise • systematic review
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Introduction
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Care in a stroke unit results in reduced disability and an increased
likelihood of returning home after stroke compared with other
forms of care. The rehabilitation provided within stroke units
is not well defined but is believed to be an important component
of care. Very early mobilization (helping patients to get up
out of bed within 24 to 48 hours of stroke symptom onset) is
performed in some stroke units and is recommended in a number
of acute stroke clinical guidelines. It is unclear whether very
early mobilization improves outcome after stroke.
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Objective
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The objective of this study was to conduct a systematic review
of randomized, controlled trials to determine the benefits and
harms of very early mobilization compared with conventional
care.
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Search Strategy and Inclusion Criteria
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We searched the Cochrane Stroke Group Trials Register (last
searched April 2008) and 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 (January 2007), the Chinese medical database
Wanfangdata (March 2007), handsearched journals, searched reference
lists, and contacted researchers in the field.
Unconfounded randomized, controlled trials comparing an intervention group that started out-of-bed mobilization within 48 hours of stroke and aimed to reduce time to first mobilization and increase the amount or frequency (or both) of mobilization, with conventional care, were eligible. Studies comparing rehabilitation delivered in different care settings (eg, stroke units versus general medical wards) were excluded.
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Data Collection
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One reviewer eliminated obviously irrelevant records. Two reviewers
independently applied selection criteria to remaining studies.
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Outcomes
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The primary outcome of interest was mortality or poor outcome
(dependency or institutionalization). Secondary outcomes included
activities of daily living, quality of life, time to walking,
adverse events, and mood.
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Main Results
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Thirty-nine trials of interest were identified, many of which
came from Chinese language journals. There were 3 eligible trials;
2 of these trials are ongoing (Very Early Rehabilitation or
Intensive Telemetry After Stroke [VERITAS], A Very Early Rehabilitation
Trial [AVERT] III), leaving one eligible randomized, controlled
trial (n=71). In this study, the experimental group had both
earlier and a higher total dose of mobilization than controls
(experimental group median time to mobilization 18.1 hours,
total dose 167 minutes; control group median time to mobilization
30.8 hours, total dose 69 minutes). No significant effect for
death and dependency was found for very early mobilization (OR
0.67,
P=0.42;
Figure).
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Reviewers’ Conclusions and Implications for Practice
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There is insufficient evidence to make any recommendation on
the practice. We found no evidence to suggest that the practice
should be discontinued where very early mobilization is already
a well-established part of stroke unit care. However, there
is insufficient evidence to suggest that the practice should
be adopted more broadly.
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Implications for Research
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Despite a significant body of potentially relevant research,
few studies met inclusion criteria. A major problem identified
during our search was that the term "early rehabilitation" was
used to define interventions spanning a time interval up to
3 months poststroke. Larger, well-designed studies are needed
in this field and the importance of clearly defining both the
start time poststroke and the precise nature of the intervention
needs to be stressed.
Note: The full text of this review is available in the Cochrane Library. The full article should be cited as: Bernhardt J, Thuy MNT, Collier JM, Legg LA. Very early versus delayed mobilization after stroke. The Cochrane Library. 2009; Issue 1.
Received February 8, 2009;
accepted February 24, 2009.
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Introduction
Objective