Timing of initial mobilisation after acute stroke-relation to 180 day outcomes

Abstract

Background and Rationale: The recent AVERT trial results (Bernhardt, 2015) have increased uncertainty regarding when mobilisation should commence following stroke, and the relative importance of intensity versus timing. We investigated the relationship between timing of initial mobilisation and outcomes using 'real world' data from the Australian Stroke Clinical Registry (Au- SCR). Methods: Data from AuSCR registrants admitted with stroke to 23 Queensland hospitals between July 2012 and December 2014 were used. Cases of in-hospital stroke and transfers from other hospitals were excluded. Initial mobilisation occurring on the day of admission was defined as Very Early Initial Mobilisation (VEIM), and on the subsequent day as Early Initial Mobilisation (EIM). The relationship between timing of initial mobilisation and death within 180 days was assessed using Cox proportional hazards regression, and Health-related Quality of Life (HR-QoL) outcomes (EQ5D-3L visual analogue scale, deaths coded as 0) using median regression. Models were adjusted for patient demographics, stroke severity, stroke type, and patient clustering. Results: Among 5337 episodes of care (median age 75 years, 54% male, 80% ischaemic stroke, 35% able to walk independently on admission), 36% received VEIM, 35% EIM, 12% were mobilised later, and 17% never mobilised. VAS data were available for 2749 first episodes. Hazard of death within 180 days was significantly lower in the VEIM group when compared to EIM alone (hazard ratio (HR): 0.68, 95% CI: 0.54-0.86, p = 0.001) or to those mobilised later (HR: 0.58, 95% CI: 0.47-0.72, p < 0.001). Registrants receiving VEIM also reported better HR-QoL when compared to EIM alone (EQ5D-3L VAS coefficient 5.16, 95% CI: 3.36-6.97, p < 0.001), or to registrants mobilised later (coefficient 6.29, 95% CI: 4.58-8.01, p < 0.001). Conclusion: In this observational study, VEIM following acute stroke was associated with improved survival and HRQoL. Amount, rather than timing of mobilisation may explain the poorer outcomes found in the intervention group in the AVERT study.<br />