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Correspondence |

Early Mobilization Testing in Patients With Acute StrokeEarly Mobilization After Stroke FREE TO VIEW

Julie Bernhardt, PhD; on behalf of the AVERT Trialist Collaboration
Author and Funding Information

From the Stroke Division, Florey Neuroscience Institutes.

Correspondence to: Julie Bernhardt, PhD, Level 1, Florey Neuroscience Institutes, 245 Burgundy St, Heidelberg, Melbourne, VIC, Australia, 3081; e-mail: J.bernhardt@unimelb.edu.au


Funding/Support: The AVERT trial has been funded by grants from the National Health and Medical Research Council, Australia [NHMRC Grant 386201]; the National Heart Foundation; Affinity Health; Chest, Heart and Stroke Scotland; Northern Ireland Chest Heart and Stroke; The Stroke Association UK; and Singapore Health. J Bernhardt is currently funded by an Australian Research Council Future Fellowship [FTO991086].

Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


© 2012 American College of Chest Physicians


Chest. 2012;141(6):1641-1642. doi:10.1378/chest.12-0296
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Published online

For the past 11 years, we have been studying very early mobilization (EM) (out of bed) in people with acute stroke. The elegant review by Schweickert and Kress1 in a recent issue of CHEST (December 2011) of the emerging research on EM of patients treated in the ICU brought home the parallels that exist between EM research, regardless of the population studied.

Inactivity, at least in the first days to weeks, appears to be the norm after having a stroke or being managed in the ICU. Inactivity may simply be a consequence of the intensive monitoring, investigation, and treatment protocols, combined with high dependence on others to move. Or bed rest may be consciously prescribed by the treating team. There is no doubt, however, that the potential harms of bed rest, and the benefits of activity, both outlined by Schweickert and Kress,1 should provide incentive for us to minimize bed rest as much, and as soon, as possible. In the stroke population and perhaps more broadly, further incentive for promoting early physical activity comes from experimental studies demonstrating the experience-dependent nature of neuroplasticity2 and the role physical activity plays in helping drive recovery of the damaged brain. In short, it is biologically plausible that EM may be helpful for acute patients, if it is not harmful.

The question of harm cannot be ignored. Cardiovascular and respiratory stability drive many decisions about out-of-bed activity in clinical practice. Of course “stability” is not always easy to define. In stroke, there is also concern that activity may diminish blood flow in an already injured brain. Not surprisingly, therefore, early EM research has addressed whether it is safe and feasible. In ICU studies to date (which exclude stroke), EM appears to be safe. Our phase 2 trial (AVERT [A Very Early Rehabilitation Trial]) found very early and frequent mobilization ( < 24 h after stroke) to be safe, feasible,3 and cost effective4; it also promoted early return of unassisted walking.5 Patients with hemorrhagic or ischemic stroke (any age or stroke severity) admitted to a stroke unit were eligible. Physiologic entry criteria applied, and patients needed to be rousable, but not fully conscious. AVERT phase 3 is now under way. Almost 1,200 patients (final N = 2,104) from five countries have participated to date, and we expect trial recruitment to end in early 2015.

EM represents a significant paradigm shift. The clinical trials currently under way across a range of populations will help inform the development of evidence-based protocols.

Role of sponsors: The National Health and Medical Research Council, Australia, has been the key sponsor for the trial, providing project grant support. Trial oversite is via an independent committee.

Other contributions: We also acknowledge the operational infrastructure support provided by the Victorian State Government, which helps fund the Coordinating Centre for this trial.

Schweickert WD, Kress JP. Implementing early mobilization interventions in mechanically ventilated patients in the ICU. Chest. 2011;1406:1612-1617. [CrossRef] [PubMed]
 
Cramer SC, Sur M, Dobkin BH, et al. Harnessing neuroplasticity for clinical applications. Brain. 2011;134pt 6:1591-1609. [CrossRef] [PubMed]
 
Bernhardt J, Dewey H, Thrift A, Collier J, Donnan G. A very early rehabilitation trial for stroke (AVERT): phase II safety and feasibility. Stroke. 2008;392:390-396. [CrossRef] [PubMed]
 
Tay-Teo K, Moodie M, Bernhardt J, et al. Economic evaluation alongside a phase II, multi-centre, randomised controlled trial of very early rehabilitation after stroke (AVERT). Cerebrovasc Dis. 2008;265:475-481. [CrossRef] [PubMed]
 
Cumming TB, Thrift AG, Collier JM, et al. Very early mobilization after stroke fast-tracks return to walking: further results from the phase II AVERT randomized controlled trial. Stroke. 2011;421:153-158. [CrossRef] [PubMed]
 

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References

Schweickert WD, Kress JP. Implementing early mobilization interventions in mechanically ventilated patients in the ICU. Chest. 2011;1406:1612-1617. [CrossRef] [PubMed]
 
Cramer SC, Sur M, Dobkin BH, et al. Harnessing neuroplasticity for clinical applications. Brain. 2011;134pt 6:1591-1609. [CrossRef] [PubMed]
 
Bernhardt J, Dewey H, Thrift A, Collier J, Donnan G. A very early rehabilitation trial for stroke (AVERT): phase II safety and feasibility. Stroke. 2008;392:390-396. [CrossRef] [PubMed]
 
Tay-Teo K, Moodie M, Bernhardt J, et al. Economic evaluation alongside a phase II, multi-centre, randomised controlled trial of very early rehabilitation after stroke (AVERT). Cerebrovasc Dis. 2008;265:475-481. [CrossRef] [PubMed]
 
Cumming TB, Thrift AG, Collier JM, et al. Very early mobilization after stroke fast-tracks return to walking: further results from the phase II AVERT randomized controlled trial. Stroke. 2011;421:153-158. [CrossRef] [PubMed]
 
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