Original ArticlePhysical Activity Early after Stroke and Its Association to Functional Outcome 3 Months Later
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.
References (42)
- et al.
Predictive value of the NIHSS for ADL outcome after ischemic hemispheric stroke: does timing of early assessment matter?
J Neurol Sci
(2010) - et al.
Monitoring of physical activity after stroke: a systematic review of accelerometry-based measures
Arch Phys Med Rehabil
(2010) - et al.
Classification and natural history of clinically identifiable subtypes of cerebral infarction
Lancet
(1991) - et al.
Bed rest: a potentially harmful treatment needing more careful evaluation
Lancet
(1999) - et al.
Sedentary behaviors and subsequent health outcomes in adults a systematic review of longitudinal studies, 1996-2011
Am J Prev Med
(2011) Organised inpatient (stroke unit) care for stroke
Cochrane Database Syst Rev
(2013)- et al.
Comparison of neurological scales and scoring systems for acute stroke prognosis
Stroke
(1996) - et al.
Comprehensive stroke units: a review of comparative evidence and experience
Int J Stroke
(2013) - et al.
Safety and feasibility of an early mobilization program for patients with aneurysmal subarachnoid hemorrhage
Phys Ther
(2013) - et al.
Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit: a retrospective cohort study
Phys Ther
(2013)
Move to improve: the feasibility of using an early mobility protocol to increase ambulation in the intensive and intermediate care settings
Phys Ther
Early mobilization out of bed after ischaemic stroke reduces severe complications but not cerebral blood flow: a randomized controlled pilot trial
Clin Rehabil
Very early rehabilitation or intensive telemetry after stroke: a pilot randomised trial
Cerebrovasc Dis
Very early mobilisation and complications in the first 3 months after stroke: further results from phase II of A Very Early Rehabilitation Trial (AVERT)
Cerebrovasc Dis
An early mobilization protocol successfully delivers more and earlier therapy to acute stroke patients: further results from phase II of AVERT
Neurorehabil Neural Repair
Very early mobilization after stroke fast-tracks return to walking: further results from the phase II AVERT randomized controlled trial
Stroke
Outcome after mobilization within 24 hours of acute stroke: a randomized controlled trial
Stroke
Evaluation of a body-worn sensor system to measure physical activity in older people with impaired function
Phys Ther
Relative validity of three accelerometer models for estimating energy expenditure during light activity
J Phys Act Health
Changes in physical activity and related functional and disability levels in the first six months after stroke: a longitudinal follow-up study
J Rehabil Med
Physical activity in hospitalised stroke patients
Stroke Res Treat
Cited by (65)
Association of Physical Activity and Nutritional Intake with Muscle Quantity and Quality Changes in Acute Stroke Patients
2022, Journal of Stroke and Cerebrovascular DiseasesCitation Excerpt :Furthermore, in terms of nutritional intake, adequate total energy and protein intake prevent muscle loss.13 These studies suggest that physical activity and nutrition prevent muscle wasting.10-13 However, to the best of our knowledge, no reports have examined the association of physical activity and nutritional status with changes in muscle properties, especially in the acute post-stroke period.
Different association between physical activity and physical function according to walking independence in hospital-based rehabilitation program patients with sub-acute stroke
2022, Clinical Neurology and NeurosurgeryCitation Excerpt :The promotion of physical activity in patients with stroke is a key factor in preventing recurrent stroke [1,2]. In addition, increasing physical activity is related to the improvement of functional recovery in patients with acute and sub-acute stroke [3,4]. However, patients with stroke undergoing inpatient rehabilitation spend most of their time sedentary [5,6].
Application of intelligent rehabilitation equipment in occupational therapy for enhancing upper limb function of patients in the whole phase of stroke
2021, Medicine in Novel Technology and DevicesExploring liminality in the co-design of rehabilitation environments: The case of one acute stroke unit
2021, Health and PlaceCitation Excerpt :Specialised stroke care is delivered by a multidisciplinary team typically consisting of doctors, nurses, therapists, psychologists, and dietitians that meet regularly to share updates and plan care based on patient needs and according to predetermined National Stroke guidelines (Intercollegiate Working Party for Stroke, 2012). These guidelines are based on a hierarchy of evidence and clinical consensus for example promoting independent patient activity in the acute phase of stroke is recommended as it is associated with improved outcomes such as personal independence (Askim et al., 2014; Intercollegiate and Stroke Working Party, 2016; Lohse et al., 2014). UK stroke units are currently required to submit data according to specified quality criteria including whether patients receive 45 min of appropriate therapy (Occupational Therapy, Physiotherapy and Speech and Language therapy) for a minimum of five days per week (Intercollegiate Working Party for Stroke, 2012).
Development and Validation of Machine Learning-Based Prediction for Dependence in the Activities of Daily Living after Stroke Inpatient Rehabilitation: A Decision-Tree Analysis
2020, Journal of Stroke and Cerebrovascular DiseasesIDENTIFYING PROFILES OF STROKE PATIENTS BENEFITTING FROM ADDITIONAL TRAINING: A LATENT CLASS ANALYSIS APPROACH
2024, Journal of Rehabilitation Medicine
Sources of funding: This study was supported through the Norwegian Fund for Postgraduate Training in Physiotherapy.