Efficacy and Safety of Very Early Mobilization in Patients with Acute Stroke: A Systematic Review and Meta-analysis

Tao Xu, Xinyuan Yu, Shu Ou, Xi Liu, Jinxian Yuan, Yangmei Chen, Tao Xu, Xinyuan Yu, Shu Ou, Xi Liu, Jinxian Yuan, Yangmei Chen

Abstract

Whether very early mobilization (VEM) improves outcomes in stroke patients and reduces immobilization-related complications (IRCs) is currently unknown. The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of VEM in acute stroke patients following admission. Medline, Embase, and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials (RCTs) that examined the efficacy or safety of VEM in patients with acute stroke. VEM was defined as out of bed activity commencing within 24 or 48 hours after the onset of stroke. A total of 9 RCTs with 2,803 participants were included. Upon analysis, VEM was not associated with favorable functional outcomes (modified Ranking Scale: 0-2) at 3 months [relative risk (RR): 0.96; 95% confidence interval (CI): 0.86-1.06]; VEM did not reduce the risk of IRCs during follow up. With respect to safety outcomes, VEM was not associated with a higher risk of death (RR: 1.04; 95% CI: 0.52-2.09) and did not increase the risk of neurological deterioration or incidence of falls with injury. In conclusion, pooled data from RCTs concluded that VEM is not associated with beneficial effects when carried out in patients 24 or 48 hours after the onset of a stroke.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Figure 1
Figure 1
Flowchart of the literature search performed.
Figure 2
Figure 2
Forest plots of efficacy and safety outcomes of very early mobilization at 3 months. The diamond indicates the estimated relative risk (RR) or standardized mean differences (SMD) (95% confidence interval). The p-value showed on each figure is for heterogeneity test. The modified Rankin Scale (0–2): p for overall effect = 0.40, Q = 6.73 (A). Mortality: p for overall effect = 0.90, Q = 13.62 (B). Barthel Index: p for overall effect = 0.23, Q = 43.22 (C). National Institutes of Health Stroke Scale: p for overall effect = 0.54, Q = 0.11 (D).
Figure 3
Figure 3
Forest plots of primary efficacy and safety outcomes stratified by starting time of very early mobilization. The diamond indicates the estimated relative risk (RR) (95% confidence interval). The p-value showed on each figure is for heterogeneity test. The modified Rankin Scale (0–2) at 3 months: within 24 hours, p for overall effect = 0.98, Q = 15.20; within 48 hours, p for overall effect = 0.95, Q = 0.12 (A). Mortality stratified by starting time of VEM: within 24 hours, p for overall effect = 0.23, Q = 5.03; within 48 hours, p for overall effect = 0.05, Q = 1.35 (B).
Figure 4
Figure 4
Forest plots of primary efficacy and safety outcomes stratified by stroke type. The diamond indicates the estimated relative risk (RR) (95% confidence interval). The p-value showed on each figure is for heterogeneity test. Modified Rankin Scale (0–2) at 3 months: ischemic stroke, p for overall effect = 0.90, Q = 0.13; any stroke, p for overall effect = 0.82, Q = 13.07 (A). Mortality at 3 months: ischemic stroke, p for overall effect = 0.40, Q = 0.65; any stroke, p for overall effect = 0.10, Q = 3.47 (B).
Figure 5
Figure 5
Risk of bias: A summary table for each risk of bias item for each study.

References

    1. O’Donnell MJ, et al. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet (London, England) 2016;388:761–775. doi: 10.1016/S0140-6736(16)30506-2.
    1. Langhorne P, et al. Stroke unit care benefits patients with intracerebral hemorrhage: systematic review and meta-analysis. Stroke; a journal of cerebral circulation. 2013;44:3044–3049. doi: 10.1161/STROKEAHA.113.001564.
    1. Langhorne P, de Villiers L, Pandian JD. Applicability of stroke-unit care to low-income and middle-income countries. The Lancet. Neurology. 2012;11:341–348. doi: 10.1016/S1474-4422(12)70024-8.
    1. van Wijk R, Cumming T, Churilov L, Donnan G, Bernhardt J. An early mobilization protocol successfully delivers more and earlier therapy to acute stroke patients: further results from phase II of AVERT. Neurorehabilitation and neural repair. 2012;26:20–26. doi: 10.1177/1545968311407779.
    1. Poletto SR, et al. Early mobilization in ischemic stroke: a pilot randomized trial of safety and feasibility in a public hospital in Brazil. Cerebrovascular diseases extra. 2015;5:31–40. doi: 10.1159/000381417.
    1. Bernhardt J, Dewey H, Thrift A, Collier J, Donnan G. A very early rehabilitation trial for stroke (AVERT): phase II safety and feasibility. Stroke; a journal of cerebral circulation. 2008;39:390–396. doi: 10.1161/STROKEAHA.107.492363.
    1. Bernhardt J, English C, Johnson L, Cumming TB. Early mobilization after stroke: early adoption but limited evidence. Stroke; a journal of cerebral circulation. 2015;46:1141–1146. doi: 10.1161/STROKEAHA.114.007434.
    1. Krakauer JW, Carmichael ST, Corbett D, Wittenberg GF. Getting neurorehabilitation right: what can be learned from animal models? Neurorehabilitation and neural repair. 2012;26:923–931. doi: 10.1177/1545968312440745.
    1. Indredavik B, Rohweder G, Naalsund E, Lydersen S. Medical complications in a comprehensive stroke unit and an early supported discharge service. Stroke; a journal of cerebral circulation. 2008;39:414–420. doi: 10.1161/STROKEAHA.107.489294.
    1. McLean DE. Medical complications experienced by a cohort of stroke survivors during inpatient, tertiary-level stroke rehabilitation. Archives of physical medicine and rehabilitation. 2004;85:466–469. doi: 10.1016/S0003-9993(03)00484-2.
    1. Parry SM, Puthucheary ZA. The impact of extended bed rest on the musculoskeletal system in the critical care environment. Extreme physiology & medicine. 2015;4:16. doi: 10.1186/s13728-015-0036-7.
    1. Herkner, H., Arrich, J., Havel, C. & Mullner, M. Bed rest for acute uncomplicated myocardial infarction. The Cochrane database of systematic reviews, CD003836 (2007).
    1. Brower RG. Consequences of bed rest. Critical care medicine. 2009;37:S422–428. doi: 10.1097/CCM.0b013e3181b6e30a.
    1. Klein K, Mulkey M, Bena JF, Albert NM. Clinical and psychological effects of early mobilization in patients treated in a neurologic ICU: a comparative study. Critical care medicine. 2015;43:865–873. doi: 10.1097/CCM.0000000000000787.
    1. Bernhardt J, et al. Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet (London, England) 2015;386:46–55. doi: 10.1016/S0140-6736(15)00692-3.
    1. Sundseth A, Thommessen B, Ronning OM. Outcome after mobilization within 24 hours of acute stroke: a randomized controlled trial. Stroke; a journal of cerebral circulation. 2012;43:2389–2394. doi: 10.1161/STROKEAHA.111.646687.
    1. Bernhardt, J., Thuy, M. N., Collier, J. M. & Legg, L. A. Very early versus delayed mobilisation after stroke. The Cochrane database of systematic reviews, CD006187 (2009).
    1. Herisson F, et al. Early Sitting in Ischemic Stroke Patients (SEVEL): A Randomized Controlled Trial. PloS one. 2016;11:e0149466. doi: 10.1371/journal.pone.0149466.
    1. Chippala P, Sharma R. Effect of very early mobilisation on functional status in patients with acute stroke: a single-blind, randomized controlled trail. Clinical rehabilitation. 2016;30:669–675. doi: 10.1177/0269215515596054.
    1. Liu N, et al. Randomized controlled trial of early rehabilitation after intracerebral hemorrhage stroke: difference in outcomes within 6 months of stroke. Stroke; a journal of cerebral circulation. 2014;45:3502–3507. doi: 10.1161/STROKEAHA.114.005661.
    1. Diserens K, et al. Early mobilization out of bed after ischaemic stroke reduces severe complications but not cerebral blood flow: a randomized controlled pilot trial. Clinical rehabilitation. 2012;26:451–459. doi: 10.1177/0269215511425541.
    1. Langhorne P, et al. Cerebrovascular diseases (Basel, Switzerland) 2010. Very early rehabilitation or intensive telemetry after stroke: a pilot randomised trial; pp. 352–360.
    1. Zeiler SR, et al. Paradoxical Motor Recovery From a First Stroke After Induction of a Second Stroke: Reopening a Postischemic Sensitive Period. Neurorehabilitation and neural repair. 2016;30:794–800. doi: 10.1177/1545968315624783.
    1. Stinear, C. M. Stroke rehabilitation research needs to be different to make a difference. F1000Research5 (2016).
    1. Murphy TH, Corbett D. Plasticity during stroke recovery: from synapse to behaviour. Nature reviews. Neuroscience. 2009;10:861–872. doi: 10.1038/nrn2735.
    1. Bernhardt J, et al. Prespecified dose-response analysis for A Very Early Rehabilitation Trial (AVERT) Neurology. 2016;86:2138–2145. doi: 10.1212/WNL.0000000000002459.
    1. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ (Clinical research ed.) 2009;339:b2535. doi: 10.1136/bmj.b2535.
    1. Higgins JP, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ (Clinical research ed.) 2011;343:d5928. doi: 10.1136/bmj.d5928.
    1. Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC medical research methodology. 2005;5:13. doi: 10.1186/1471-2288-5-13.
    1. Borenstein M, Higgins JP, Hedges LV, Rothstein HR. Basics of meta-analysis: I2 is not an absolute measure of heterogeneity. Research synthesis methods. 2017;8:5–18. doi: 10.1002/jrsm.1230.
    1. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ (Clinical research ed.) 2003;327:557–560. doi: 10.1136/bmj.327.7414.557.
    1. Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50:1088–1101. doi: 10.2307/2533446.
    1. Egger M, Davey Smith G, Schneider M, Minder C. BMJ (Clinical research ed.) 1997. Bias in meta-analysis detected by a simple, graphical test; pp. 629–634.

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