Very Early Mobilization After Stroke Does Not Improve Survival Over Usual Care
In addition to survival and recovery, the researchers considered secondary outcomes such as activities of daily living, dependency, quality of life, and length of hospital stay.
Very early mobilization (VEM) initiated ≤48 hours after onset of stroke symptoms is not associated with an improvement in survival or recovery in patients with acute stroke, according to a Cochrane Database review. In addition, researchers reported that VEM appears to result in similar survival and recovery outcomes as seen with delayed mobilization.
The researchers searched the Cochrane Stroke Group Trials Register and 19 other electronic databases for randomized controlled trials consisting of patients with acute stroke who underwent VEM or usual care, the latter of which involved a later time to first mobilization. Death or poor outcome, including dependency or institutionalization, at the end of scheduled follow-up made up the primary outcome. In addition, the investigators compared VEM vs usual care in terms of activities of daily living, extended activities of daily living, dependency, quality of life, walking ability, patient mood, complications, and length of hospital stay.
A total of 9 randomized controlled trials consisting of a pooled cohort of 2958 patients with acute stroke were included in the final review. In the VEM and usual care groups, the median delay to mobilization after stroke onset was 18.5 hours and 33.3 hours, respectively. Patients who received VEM had a shorter mean length of hospital stay compared with patients who received usual care (mean difference −1.44 days; 95% CI, −2.28 to −0.60 days; P =.0008; low-quality evidence).
Participants who underwent VEM and who had a poor outcome had a slightly higher yet statistically similar likelihood of mortality compared with participants who received usual care (51% vs 49%, respectively; odds ratio 1.08; 95% CI, 0.92-1.26; P =.36; moderate-quality evidence). In 8 trials with a total of 2570 participants, mortality was nonsignificantly lower among patients who received delayed mobilization vs VEM (7.0% vs 8.5%; odds ratio 1.27; 95% CI, 0.95-1.70; P =.11; moderate-quality evidence).
Patients who received VEM had a higher mean activities of daily living score at last follow-up than patients who received delayed mobilization (mean difference, 1.94; 95% CI, 0.75-3.13; P =.001; low-quality evidence); however, the researchers reported substantial heterogeneity in the analysis (93%).
"We believe that the evidence supported a cautious approach to active mobilization within 24 hours of stroke onset because the single largest trial (AVERT III 2015), and a sensitivity analysis of trials recruiting within 24 hours, raised the possibility that VEM commencing within 24 hours may carry some increased hazard," the researchers concluded. "In addition, low-quality evidence from an exploratory network meta-analysis indicated that mobilization at around 24 hours may be associated with the best outcome."
Langhorne P, Collier JM, Bate PJ, Thuy MNT, Bernhardt J. Very early versus delayed mobilisation after stroke (review). Cochrane Database Syst Rev. 2018;10:CD006187.