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. 2018 Oct 16;10(10):CD006187.
doi: 10.1002/14651858.CD006187.pub3.

Very early versus delayed mobilisation after stroke

Peter Langhorne  1 , Janice M Collier, Patricia J Bate, Matthew Nt Thuy, Julie Bernhardt
Affiliations

Very early versus delayed mobilisation after stroke

Peter Langhorne et al. Cochrane Database Syst Rev. .

Abstract

Background: Very early mobilisation (VEM) is performed in some stroke units and recommended in some acute stroke clinical guidelines. However, it is unclear whether very early mobilisation independently improves outcome after stroke.

Objectives: To determine whether very early mobilisation (started as soon as possible, and no later than 48 hours after onset of symptoms) in people with acute stroke improves recovery (primarily the proportion of independent survivors) compared with usual care.

Search methods: We searched the Cochrane Stroke Group Trials Register (last searched 31 July 2017). We also systematically searched 19 electronic databases including; CENTRAL; 2017, Issue 7 in the Cochrane Library (searched July 2017), MEDLINE Ovid (1950 to August 2017), Embase Ovid (1980 to August 2017), CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to August 2017) , PsycINFO Ovid (1806 to August 2017), AMED Ovid (Allied and Complementary Medicine Database), SPORTDiscus EBSCO (1830 to August 2017). We searched relevant ongoing trials and research registers (searched December 2016), the Chinese medical database, Wanfangdata (searched to November 2016), and reference lists, and contacted researchers in the field.

Selection criteria: Randomised controlled trials (RCTs) of people with acute stroke, comparing an intervention group that started out-of-bed mobilisation within 48 hours of stroke, and aimed to reduce time-to-first mobilisation, with or without an increase in the amount or frequency (or both) of mobilisation activities, with usual care, where time-to-first mobilisation was commenced later.

Data collection and analysis: Two review authors independently selected trials, extracted data, assessed risk of bias, and applied the GRADE approach to assess the quality of the evidence. The primary outcome was death or poor outcome (dependency or institutionalisation) at the end of scheduled follow-up. Secondary outcomes included death, dependency, institutionalisation, activities of daily living (ADL), extended ADL, quality of life, walking ability, complications (e.g. deep vein thrombosis), patient mood, and length of hospital stay. We also analysed outcomes at three-month follow-up.

Main results: We included nine RCTs with 2958 participants; one trial provided most of the information (2104 participants). The median (range) delay to starting mobilisation after stroke onset was 18.5 (13.1 to 43) hours in the VEM group and 33.3 (22.5 to 71.5) hours in the usual care group. The median difference within trials was 12.7 (4 to 45.6) hours. Other differences in intervention varied between trials; in five trials, the VEM group were also reported to have received more time in therapy, or more mobilisation activity.Primary outcome data were available for 2542 of 2618 (97.1%) participants randomized and followed up for a median of three months. VEM probably led to similar or slightly more deaths and participants who had a poor outcome, compared with delayed mobilisation (51% versus 49%; odds ratio (OR) 1.08, 95% confidence interval (CI) 0.92 to 1.26; P = 0.36; 8 trials; moderate-quality evidence). Death occurred in 7% of participants who received delayed mobilisation, and 8.5% of participants who received VEM (OR 1.27, 95% CI 0.95 to 1.70; P = 0.11; 8 trials, 2570 participants; moderate-quality evidence), and the effects on experiencing any complication were unclear (OR 0.88; 95% CI 0.73 to 1.06; P = 0.18; 7 trials, 2778 participants; low-quality evidence). Analysis using outcomes collected only at three-month follow-up did not alter the conclusions.The mean ADL score (measured at end of follow-up, with the 20-point Barthel Index) was higher in those who received VEM compared with the usual care group (mean difference (MD) 1.94, 95% CI 0.75 to 3.13, P = 0.001; 8 trials, 9 comparisons, 2630/2904 participants (90.6%); low-quality evidence), but there was substantial heterogeneity (93%). Effect sizes were smaller for outcomes collected at three-month follow-up, rather than later.The mean length of stay was shorter in those who received VEM compared with the usual care group (MD -1.44, 95% CI -2.28 to -0.60, P = 0.0008; 8 trials, 2532/2618 participants (96.7%); low-quality evidence). Confidence in the answer was limited by the variable definitions of length of stay. The other secondary outcome analyses (institutionalisation, extended activities of daily living, quality of life, walking ability, patient mood) were limited by lack of data.Sensitivity analyses by trial quality: none of the outcome conclusions were altered if we restricted analyses to trials with the lowest risk of bias (based on method of randomization, allocation concealment, completeness of follow-up, and blinding of final assessment), or information about the amount of mobilisation.Sensitivity analysis by intervention characteristics: analyses restricted to trials where the mean VEM time-to-first mobilisation was less than 24 hours, showed an odds of death of 1.35 (95% CI 0.99 to 1.83; P = 0.06; I² = 25%; 5 trials). Analyses restricted to the trials that clearly reported a more prolonged out-of-bed activity showed a similar primary outcome (OR 1.14; 0.96 to 1.35; P = 0.13; I² = 28%; 5 trials), and odds of death (OR 1.27; 0.93 to 1.73; P = 0.13; I² = 0%; 4 trials) to the main analysis.Exploratory network meta-analysis (NMA): we were unable to analyze by the amount of therapy, but low-quality evidence indicated that time-to-first mobilisation at around 24 hours was associated with the lowest odds of death or poor outcome, compared with earlier or later mobilisation.

Authors' conclusions: VEM, which usually involved first mobilisation within 24 hours of stroke onset, did not increase the number of people who survived or made a good recovery after their stroke. VEM may have reduced the length of stay in hospital by about one day, but this was based on low-quality evidence. Based on the potential hazards reported in the single largest RCT, the sensitivity analysis of trials commencing mobilisation within 24 hours, and the NMA, there was concern that VEM commencing within 24 hours may carry an increased risk, at least in some people with stroke. Given the uncertainty around these effect estimates, more detailed research is still required.

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Conflict of interest statement

Several of the review authors were trialists in at least one of the included trials. However, we allocated trial selection decisions in a manner that avoided trialists making decisions about their own trials.

Peter Langhorne: PL is trialist in two of the included trials (AVERT III 2015; Langhorne 2010). However, trial selection decisions were allocated in a manner to avoid making decisions about his own trials. Janice M Collier: JC is trialist in two of the included trials (AVERT II 2008; AVERT III 2015). However, trial selection decisions were allocated in a manner to avoid making decisions about her own trials. Patricia J Bate: none known Matthew NT Thuy: none known Julie Bernhardt: JB is trialists in three of the included trials (AVERT II 2008; AVERT III 2015; Langhorne 2010). However, trial selection decisions were allocated in a manner to avoid making decisions about her own trials.

Figures

1
1
Study flow diagram
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
4
4
Network plot of all trials. Each point shows the time‐to‐first mobilisation (TTFM) classifications. The lines show the number of trials directly comparing each TTFM category.
5
5
Network meta‐analysis plot for poor outcome (death or dependency at 3 months). The treatment column shows the time‐to‐first mobilisation (TTFM) categories. The results are the odds ratio (95% confidence interval) for the odds of a poor outcome with TTFM of 24 hours as the reference (OR = 1.0).
6
6
Network meta‐analysis plot for death at 3 months. The treatment column shows the time‐to‐first mobilisation (TTFM) categories. The results are the odds ratio (95% confidence interval) for the odds of death with TTFM of 24 hours as the reference (OR = 1.0).
1.1
1.1. Analysis
Comparison 1 Very early mobilisation (VEM) versus standard care (measured at end of scheduled follow‐up), Outcome 1 Death or poor outcome.
1.2
1.2. Analysis
Comparison 1 Very early mobilisation (VEM) versus standard care (measured at end of scheduled follow‐up), Outcome 2 Death.
1.3
1.3. Analysis
Comparison 1 Very early mobilisation (VEM) versus standard care (measured at end of scheduled follow‐up), Outcome 3 Death or dependence (modified Rankin score 3 to 6).
1.4
1.4. Analysis
Comparison 1 Very early mobilisation (VEM) versus standard care (measured at end of scheduled follow‐up), Outcome 4 Death or institutional care.
1.5
1.5. Analysis
Comparison 1 Very early mobilisation (VEM) versus standard care (measured at end of scheduled follow‐up), Outcome 5 Activities of daily living (ADL) score.
1.6
1.6. Analysis
Comparison 1 Very early mobilisation (VEM) versus standard care (measured at end of scheduled follow‐up), Outcome 6 Subjective Health Status score.
1.7
1.7. Analysis
Comparison 1 Very early mobilisation (VEM) versus standard care (measured at end of scheduled follow‐up), Outcome 7 Able to walk.
1.8
1.8. Analysis
Comparison 1 Very early mobilisation (VEM) versus standard care (measured at end of scheduled follow‐up), Outcome 8 Mobility score.
1.9
1.9. Analysis
Comparison 1 Very early mobilisation (VEM) versus standard care (measured at end of scheduled follow‐up), Outcome 9 Any complication: participants who experienced at least one complication.
1.10
1.10. Analysis
Comparison 1 Very early mobilisation (VEM) versus standard care (measured at end of scheduled follow‐up), Outcome 10 Type of complication: participants who experienced at least one complication.
1.11
1.11. Analysis
Comparison 1 Very early mobilisation (VEM) versus standard care (measured at end of scheduled follow‐up), Outcome 11 Mood score.
1.12
1.12. Analysis
Comparison 1 Very early mobilisation (VEM) versus standard care (measured at end of scheduled follow‐up), Outcome 12 Length of acute hospital stay (days).
2.1
2.1. Analysis
Comparison 2 Very early mobilisation versus standard care (results at 3 months), Outcome 1 Death or poor outcome.
2.2
2.2. Analysis
Comparison 2 Very early mobilisation versus standard care (results at 3 months), Outcome 2 Death.
2.3
2.3. Analysis
Comparison 2 Very early mobilisation versus standard care (results at 3 months), Outcome 3 Death or dependence (modified Rankin score 3 to 6).
2.4
2.4. Analysis
Comparison 2 Very early mobilisation versus standard care (results at 3 months), Outcome 4 Death or institutional care.
2.5
2.5. Analysis
Comparison 2 Very early mobilisation versus standard care (results at 3 months), Outcome 5 Activities of daily living (ADL) score.
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Update of

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References to studies awaiting assessment

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