Very Early Versus Delayed Mobilization After Stroke
Graeme J. Hankey MD, FRCP Section Editor:
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.
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.
Search Strategy and Inclusion Criteria
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.
One reviewer eliminated obviously irrelevant records. Two reviewers independently applied selection criteria to remaining studies.
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.
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).
Reviewers’ Conclusions and Implications for Practice
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.
Implications for Research
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.