1st Journal Reading Early mobilisation out of bed after ischaemic stroke reduces severe complications but not

cerebral blood flow: a randomized controlled pilot trial

Karin Diserens, Tiago Moreira, Lorenz Hirt, Mohamed Fouzi, Jelena Grujic, Giles Bieler, Philippe Vuadens and Patrick Michel

Clinical Rehabilitation Vol 26, 2011

Presented by : Thomas Purba Supervised by : Irma, Physiatrist

Introduction

Early mobilization and initiation of rehabilitation

May limit the development of medical complication

No controlled study has investigated the impact of the timing of mobilization on complications and cerebral blood flow.

AVERT Phase II
Cohcrane library review

No Signifance effect of early mobilization on death and dependency at 3 months and confirmed that early mobilization in the 24 hours after stroke is safe

Insufficient evidence

Need more study

Hypothesis : Earlier mobilization is better than delayed mobilizations with regard to medical complication Purpose : To compare early mobilization protocol moving the patient out of bed at 52 hours with a delayed protocol of mobilization over six days in acute ischaemic stroke patient

Methods
Randomized controlled trial

Inclusion Criteria

Exclusion Criteria

>18 years old NIHSS > 6 Ischaemic stroke Inclusion within first 12 hours of admission Consent obtain

Transitory Ischaemic attack Intracerebral / subarachnoid haemorrhage

Methods
Early Mobilization
Delayed Mobilization

0 degree 24 hours

NIHSS SCORING

Heads of their beds progressively elevated over 6 days

45 degree Next 24 hours

90 degree Next 4 hours

Move out of bed 52 hours after stroke onset

Protocol restarted if 2 points worsening

Primary End Point : Severe Complication Secondary End Point : Miinor Complication Neurological deficit (NIHSS 0,2,5 days and 3 monthsafter) (modified rankin scale 10 days and 3 months after) Modification of o blood flow

Complication

Methods
Cerebral Blood Flow

24 hr

Transcranial doppler ultrsonography

Between 72 and 96 hours post stroke

ATL 500

Acuson Sequeia
Multi-dop T2 instrument

Data Analysis
Difference between 2 mobilization protocol

Exact Fisher Test

Doppler usg data

Two way ANOVA Bonferroni's post-hoc tests

Diffrence in age and length of hospital stay

Wilcoxon test Repeated measure analysis of variance ( ANOVA) using STATA Software

Diffrence in NIHSS Score

Result s 50 participants --> 42 completed the study 8 were excluded --> early transfer --> university Hospital policy

Result s

Result s

Discussion

- Apparent reduction of severe medical complication and safety early mobilization protocol on neurological scales and cerebral blood flow - This study concur with other observational studies --> prolonged bed rest --> increased complication - In line with AVERT II trial --> safety of early mobilization - This study adds data to Cohrane Review comparing early mobilization vs standard care

Discussion

- 6-7 days of bed rest --> theoretical worsening of perfussion in hypoperfused tissue --> little evidence to support the hypothesis - Sorbello et al : no statistically significance difference in complication between two groups but found prolonged stay of standard care group - Langhorne et al : lower rate of complications of immobility in the early active mobilization group --> sitting, standing, walking. This study focused on head position

Discussion

Recent AVERT study shows early mobilization protocol moved patients out of bed within 24 hr --> fastrack return to unassisted walking and improve functioal recovery. This study has diffrerent end point Keeping pstients in bed --> maintain cerebral perfussion pressure in the penumbra region --> horizontal body and head position could increase intra cranial blood flow --> <<< brain infarct volume Novak et all : cerebral vasoregulation may be altered 2 months afte stroke No study evaluated the infarct growth / neurological evolution in relationship to elevation of the head position.

Study Limitation

Small Sample Unequal drop out rate in treatment group Primary outcome is not measured in blinded way Transcranial doppler was performed in 60 % of samples

Conclusion

Apparent reduction in severe complication with early mobilisation No increase in total complication No influence on neurological 3 month outcomes or on cerebral blood flow Larger trials is needed

Thank You