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Mobilization after stroke: Is sooner better?

From the October ACP Hospitalist, copyright © 2012 by the American College of Physicians

By Kathy Holliman

Mobilization after stroke is generally considered appropriate therapy for most patients, with its potential to improve recovery and reduce complications and disabilities. There is no firm guidance, however, on how early this mobilization should begin and whether very early mobilization—within the first 24 hours—is a good idea.

The 2007 American Heart Association (AHA)/American Stroke Association (ASA) Guidelines for the Early Management of Adults with Ischemic Stroke don't give specifics on timing, but say that early mobilization “is favored because it lessens the likelihood of complications such as pneumonia, deep vein thrombosis, pulmonary embolism, and pressure sores.” When immobility is prolonged, other complications can develop, including contractures, orthopedic complications and pressure palsies, the guidelines state.

Photo by Thinkstock.

Photo by Thinkstock.



Mobilization after stroke is credited with increasing the brain's ability to remodel in the acute setting and may be neuroprotective, says S. Andrew Josephson, MD, chair of the neurohospitalist program at the University of California San Francisco.

“We know that patients who go many days or weeks without any therapy do ultimately get hurt in terms of their eventual outcome. It is not understood biologically as well as it could be, but it is an active area of research,” he said.

The guidelines aren't specific on timing, in part, because there isn't enough evidence-based research on the topic, experts said.

“The general consensus is that sometime within the first 24 to 48 hours is the time to consider mobilization,” said Kevin M. Barrett, MD, a neurohospitalist in the department of neurology at the Mayo Clinic Florida in Jacksonville. “We don't, however, have good evidence-based guidelines to direct us about the most optimal time to mobilize a stroke patient.”

Recent research: Not yet definitive

A study by Antje Sundseth, MD, and colleagues, published in the June 14, 2012 online edition of Stroke, looked at whether mobilization within the first 24 hours of admission to a hospital for stroke would reduce poor outcomes (as defined by modified Rankin scale score, mortality rate, neurological impairment and dependency).

The prospective, randomized controlled trial found a nonsignificant trend toward increased poor outcome among patients mobilized very early compared to those mobilized 24 to 48 hours after stroke admission (“early”). The study, however, had limited power due to its small sample size. Perhaps more important, the group assigned to very early mobilization had greater stroke severity than the group mobilized within 24 to 48 hours, making direct comparison difficult.

Dr. Sundseth, in the department of neurology at Akershus University Hospital in Lørenskog, Norway, said that, given the study's limitations, it does not provide clarity about very early mobilization. “We cannot rule out that initial immobilization might be beneficial for some stroke patients,” she said. “Factors such as age, comorbidity, stroke type or severity can be of importance for the optimal time of first mobilization.”

Another randomized, controlled trial, AVERT II, also compared mobilization within 24 hours of ischemic or hemorrhagic stroke to conventional care. In the latter group, mobilization occurred at a median of 30.8 hours after stroke, though sometimes it was more than 48 hours post-stroke. The phase II trial's results, published in Cerebrovascular Diseases in 2009, identified no significant differences in stroke-related complications, including falls, between the two groups at three months. The trial was also limited by its small sample size of 71 patients, however.

More definitive results about the benefits or harms of very early mobilization are expected from AVERT III, a multicenter, randomized trial that will include 2,000 patients, the authors noted in the 2009 article. Recruitment will continue through 2012, they said, so those results aren't likely to appear soon.

Results of a pilot randomized trial, VERITAS, published in Cerebrovascular Diseases in 2010, looked at the effects of early active mobilization, automated monitoring, or both in 32 patients with either hemorrhagic or ischemic stroke who were recruited within 36 hours of stroke. Patients randomized to the early mobilization group were significantly more likely to walk by five days and were less likely to develop complications associated with immobility.

Making decisions about mobilization

Even without clear evidence-based research about timing, neurohospitalists and hospitalists are often the physicians who must help determine when patients can safely be mobilized, whether in the first 24 hours, the first 36 to 72 hours after a stroke, or later.

A patient's physiologic variables, such as blood pressure, heart rate, and oxygen saturation, can be used to determine whether he or she can be safely mobilized, Dr. Barrett said. “If a patient being mobilized for the first time develops hypotension or worsening of their neurologic deficit, then the physician should not push ahead,” he said.

Dr. Josephson agreed. Patients who are hemodynamically unstable or have fluctuating neurologic symptoms should be monitored carefully, he noted. “You would worry that potentially there could be an area of the brain that is ischemic but not yet infarcted, and the patient could be injured by decreasing perfusion and having them in an upright position within the first 24 hours,” he said.

However, he added, “For the vast majority of our stroke patients, there is unlikely to be any harm and there may potentially be a huge benefit from very early mobilization.” At his hospital, the protocol is that all patients with stroke are evaluated by physical therapy the day of or the day after admission.

The single biggest predictor of how well a person will fare after stroke is their National Institutes of Stroke Scale score, followed by age, Dr. Josephson added, but early mobilization may be another important predictor. Mobilization decisions can be complicated by the type of stroke, whether hemorrhagic or ischemic, and by stroke severity, but even very sick patients—including those in the ICU or with hemorrhagic stroke—can be considered for early mobilization if they are stable, he added.

Another major concern is when to mobilize a patient after ischemic stroke who has been treated with tissue plasminogen activator (tPA). The AHA/ASA guidelines recommend that this type of patient be kept on bed rest for the first 24-hour period and monitored closely because of the risk of bleeding complications.

The Mayo Clinic Florida recently completed a pilot, prospective study looking at the effect of early mobilization on patients treated with tPA and found no significant early risk with mobilization, Dr. Barrett said. Twenty-nine post-tPA patients at the Mayo Clinic were mobilized within the first 24 hours after stroke. At the 24-hour assessment, 75% had no adverse response to the mobilization. The remaining 25% experienced anything from dizziness to increase in diastolic blood pressure and heart rate; one patient had a worsening of neurologic deficit.

The hospital is now in the early planning stages of a randomized clinical trial of post-tPA patients to assess the effects of very early mobilization on outcomes at three months.

“Our biologic thinking is that moving these patients when it is safe leads to better outcomes,” Dr. Barrett said. “In most institutions, the decision about mobilization is made on a case-by-case basis, depending on the severity of the deficit and the patient's ability to engage with the physical therapy group. We would like to move from case-by-case clinical judgment to more of an evidence-based standard. Hopefully, we are on our way to getting that evidence.”

Protocols needed

Hospitalists, being at the forefront of stroke care at many hospitals, can play a central role in decision-making. “The model of having patients mobilized and working with rehabilitation early in their course is something that is really up to the hospitalist caring for these patients in many settings,” Dr. Josephson said. Hospitalists should be having discussions with neurologists and nursing and physical therapy staff to come up with a protocol regarding mobilization early in a patient's hospitalization, he added.

Stroke care sometimes concentrates too much on the acute treatment of stroke, like administration of thrombolytic therapy, he said. But it is important to remember that a lot of other decisions that are made very early in a patient's care really can have a tremendous impact on their eventual outcome, Dr. Josephson added.

“Unfortunately, a large number of hospitals in this country are continuing to delay mobilization past the first few days of hospitalization for reasons that are unclear,” he said. “That is a practice that should be stopped.”

Kathy Holliman is a freelance writer in Woodstown, N.J.

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Resources

Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al; American Heart Association. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007;38:1655-711. [PMID: 17431204]

Bernhardt J, Thuy MN, Collier JM, Legg LA. Very early versus delayed mobilisation after stroke. Cochrane Database Syst Rev. 2009:CD006187. [PMID: 19160268]

Langhorne P, Stott D, Knight A, Bernhardt J, Barer D, Watkins C. Very early rehabilitation or intensive telemetry after stroke: a pilot randomised trial. Cerebrovasc Dis. 2010; 29:352-60. [PMID: 20130401]

Sorbello D, Dewey HM, Churilov L, Thrift AG, Collier JM, Donnan G, et al. Very early mobilisation and complications in the first 3 months after stroke: further results from phase II of A Very Early Rehabilitation Trial (AVERT). Cerebrovasc Dis. 2009;28:378-83. [PMID: 19641313]

Sundseth A, Thommessen B, Ronning OM. Outcome After Mobilization Within 24 Hours of Acute Stroke: A Randomized Controlled Trial. Stroke. 2012. [PMID: 22700533]

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