Original Article
Physical Activity Early after Stroke and Its Association to Functional Outcome 3 Months Later

https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.12.011Get rights and content

Background

Early rehabilitation that includes early mobilization and increased amount of motor activity is hypothesized to be one of the most important factors contributing to the beneficial effect of comprehensive stroke unit treatment, whereas too much bed rest is hypothesized to be harmful. The purpose of the present study was to assess the association between early activity/bed rest and functional outcome 3 months later.

Methods

This was a prospective cohort study including patients with the diagnosis of stroke admitted to Trondheim University Hospital, Norway. Patients were eligible if they were less than 14 days poststroke and did not receive palliative care. Motor activity/bed rest was recorded in the acute phase using a standard method of observation, and the outcome was assessed by the modified Rankin Scale (mRS) score 3 months later. A proportional odds model was used to analyze the association between motor activity/bed rest and outcome. All analyses were adjusted for age, gender, stroke severity, time from stroke to observation, and prestroke function.

Results

A total of 106 patients (mean age 79.0 years, 56.6% men) were included. The odds ratio for a higher mRS score (poor outcome) was 1.04 (95% confidence interval [CI] 1.02-1.07, P = .001) as time in bed increased and .97 (95% CI .93-1.02, P = .283) as time in motor activity increased.

Conclusions

This study confirms that time in bed in the early phase is associated with poor functional outcome 3 months later, indicating that too much bed rest should be avoided in the early phase after stroke.

Introduction

For patients suffering from stroke, acute treatment in comprehensive stroke units is associated with reduction in death and dependency when compared with other stroke unit models.1 Still, stroke severity is one of the most significant predictors for functional outcome after stroke, showing a strong association with poor outcome 3 and 6 months later.2, 3 Components of stroke unit care that improve outcome seem to be multifactorial and most probably include early rehabilitation, including out of bed activity (early mobilization).4

There is an increasing interest in investigating the feasibility and potential beneficial effects of early mobilization within critically ill patients.5, 6, 7 The mechanisms behind the apparent benefits of starting rehabilitation early after stroke are still unknown. Although some studies suggest that early mobilization reduces the number of serious complications compared with delayed mobilization,8, 9 other studies, like the phase II A Very Early Rehabilitation Trial for Stroke (AVERT), show no difference in complication rates10, 11 but faster recovery of walking.12 Still others suggest that starting mobilization within 24 hours is associated with a trend toward poor outcome compared with patients mobilized between 24 and 48 hours after hospitalization as shown in the Akershus Early Mobilization in Stroke Study (AKEMIS).13 These small trials assessed the effect of early mobilization compared with delayed mobilization or standard care. However, a key distinction between AKEMIS and AVERT was that the AKEMIS tested earlier start of mobilization, whereas the AVERT trial tested an intervention that included both an earlier start and a higher total dose of mobilization in the early mobilization groups compared with standard care.13 The amount of mobilization during the early phase is likely to be important and perhaps of greater importance than the timing of mobilization.

Hence, quantifying stroke patient activity in the acute phase of care, timing of start of activity, and exploring the relationship between this early activity and longer term outcome would help our understanding in this field. A major challenge is finding suitable ways to measure activity. Accelerometer-based body-worn sensor systems typically record time spent in walking, sitting, or upright positions14 or estimate energy expenditure.15 These systems have the advantage of being able to record activity continuously over days in the patients' own home or community environment.16 However, devices are prone to failure, can be difficult to apply, or maintain in situ and few are waterproof, making them less suitable for acute care environments.17 An alternative method is structured observation, and this is the most common method used in hospitalized patients.18 This method allows a detailed description of the activity level, where the activity is performed, and who the patient interacts with19; however, because of the time-consuming nature of the method, data are typically acquired for only 1 or 2 days. As hypothesized from the stroke unit trials, the initial level of physical activity after stroke would be expected to be associated with functional outcome.20, 21 Interestingly, few studies have examined the association of early physical activity measured with either device or structured observation (behavioral mapping) with final functional outcome. Thus, the purpose of the present study was to quantify patient activity in the early phase after stroke and to assess the association between early activity and functional outcome 3 months later.

Our primary hypothesis was that patients who spend more time in bed early after stroke will have higher odds of a poorer outcome 3 months later.

The secondary hypotheses were that patients who start mobilization early and patients who spend more time in higher motor activities have higher odds of a better outcome 3 months later.

Section snippets

Study Design

This was a prospective cohort study with an initial assessment at inclusion and a follow-up assessment conducted in the patient's home 3 months later.

Participants

All patients admitted to the stroke unit at St Olavs Hospital, Trondheim University Hospital, Norway, with the diagnosis of stroke were eligible for inclusion if time from onset of stroke was less than 14 days, except for those with a devastating stroke receiving end-of-life palliative care. Eligible patients were included if they were able and

Descriptive Statistics

According to the protocol, patients were screened for inclusion once every second week to allow time for patient turnover. The total number of patients screened was not recorded, but only a few patients who refused to participate or receiving end-of-life care were excluded.

Over 18 months, 124 patients were included, which makes up 23% of all patients admitted to the stroke unit during this period. Six patients with incomplete data because of discharge before 1:00 pm on the day of observation

Discussion

This is the first study to assess the association between timing of mobilization and amount of activity, measured by behavioral mapping or instrumentation, within the first 2 weeks of stroke onset and outcome 3 months later. Our primary hypothesis was confirmed as the time spent in bed in the early phase was strongly associated with poor outcome 3 months later in the complex multivariable model, even after adjusting for stroke severity, age, prestroke function, time from stroke to observation,

Conclusions

This study confirms that time in bed in the early phase is associated with poor functional outcome 3 months later, indicating that too much bed rest should be avoided in the early phase after stroke. However, the appropriate dosage of bed rest and activity need to be defined in future research. Furthermore, time to first mobilization and time in higher motor activities was not associated with outcome. On-going research investigating the risks and benefits of higher motor activities in the early

Acknowledgments

The authors want to thank Nina Pedersen, Turid Altin, Mari Gunnes, and Kristine Rabben Fredriksen for their contribution in collecting data. The authors also want to thank Jan Chamberlain and Li Chun Quang at the Florey Institute of Neuroscience and Mental Health for processing and preparing the data for analysis and also Professor Leonid Churilov for statistical advice. Finally, the authors would like to thank all stroke patients and their families that agreed to take part in the study.

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