Does early mobilisation improve stroke outcomes?

Because stroke remains one of the leading causes of death and disability worldwide, implementation of specialized Stroke Units has proven effective in containing the risk of death and of long-term disability in stroke survivors. The question is which components of the Stroke Unit interventions are most effective in improving stroke outcomes? Early patient mobilisation is considered a pillar of multidisciplinary Stroke Unit interventions. It aims to minimize complications related to bed rest and immobility and to provide early brain stimulation, thus possibly enhancing early phenomena of brain remodelling after lesion (neuroplasticity). However, concerns have been raised about very early mobilisation after stroke, advocating potential risk of reducing blood supply to the injured brain (by raising the head up while brain blood-flow regulation may be impaired) and of further bleeding, in the event of intracerebral haemorrhages.

This recently published Cochrane Review, by Langhorne et al., has attempted to clarify 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, compared with usual care. 

High quality evidence from 9 trials with a total of 2,958 participants failed to detect differences between very early mobilisation and usual care as to death, dependency, institutional care, presence of complications, and ability to walk (although the single largest trial included in the review reported that mobilisation within 24 hours was associated with an increased risk of death and dependency). On the other hand, early mobilisation resulted in higher functional ability among survivors and in a slightly shorter length of hospital stay, but the evidence supporting these outcomes was of low quality. Low quality evidence also supported the estimate of the best time to start mobilisation, calculated as 24 hours after stroke. 

Authors concluded by recommending a cautious approach to active mobilisation within 24 hours of stroke onset. A relevant issue also is the median delay to starting mobilisation after stroke, which was 18 hours for very early versus 33 hours for usual care, with all patients mobilised within 73 hours after stroke. So, rather than questioning whether early is more effective than delayed mobilisation, this study appears to stress the need to clarify the best timing to start rehabilitation, as well as to define its optimal features, frequency, and duration.

Comment by Francesca Cecchi