Presentation 1st Journal Reading Thomas Purba MD

7/30/2019 Presentation 1st Journal Reading Thomas Purba MD

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Karin Diserens, Tiago Moreira, Lorenz Hirt, Mohamed Fouzi, Jelena Grujic, Giles Bieler,

Philippe Vuadens and Patrick Michel

Early mobilisation out of bed after ischaemic stroke

reduces severe complications but not cerebral

blood flow: a randomized controlled pilot trial

1st Journal Reading

Clinical Rehabilitation Vol 26, 2011

Presented by : Thomas Purba

Supervised by : Irma, Physiatrist


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Introduction

Early mobilization and initiation of rehabilitation

May limit the development of medical complication

No controlled study has investigated the impact of thetiming of mobilization on complications and cerebral

blood flow.


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AVERT

Phase II

No Signifance effect of early mobilization on death

and dependency at 3 months and confirmed that

early mobilization in the 24 hours after stroke is safe

Cohcrane

library

review

Insufficient

evidence

Hypothesis : Earlier mobilization is better than delayed

mobilizations with regard to medical complication

Purpose : To compare early mobilization protocol movingthe patient out of bed at 52 hours with a delayed protocol

of mobilization over six days in acute ischaemic stroke

patient

Need

more

study


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Methods

Inclusion Criteria

>18 years old

NIHSS > 6 Ischaemic stroke

Inclusion within first 12hours of admission

Consent obtain

Exclusion Criteria

Transitory Ischaemic

attack

Intracerebral /

subarachnoid

haemorrhage

Randomized controlled trial


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Methods

Early Mobilization Delayed Mobilization

0 degree

24 hours

45 degree

Next 24 hours

90 degreeNext 4 hours

Move out of bed

52 hours after stroke

onset

Heads of their beds progressively

elevated over 6 daysNIHSS SCORING

Protocolrestarted if 2

points

worsening

Complication

Primary End Point : Severe

Complication

Secondary End Point :

Miinor Complication

Neurological deficit

(NIHSS 0,2,5 days and 3

monthsafter)

(modified rankin scale 10 days and 3

months after)Modification of o blood flow


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Methods

Transcranial doppler

ultrsonography

Cerebral Blood Flow

ATL 500

Acuson Sequeia

Multi-dop T2

instrument

24 hr

Between 72

and 96 hourspost stroke


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Difference between 2

mobilization protocolExact Fisher Test

Doppler usg dataTwo way ANOVA

Bonferroni's post-hoc tests

Diffrence in age and length of

hospital stayWilcoxon test

Diffrence in NIHSS Score

Repeated measure analysis of

variance ( ANOVA) using STATA

Software

Data Analysis


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Result

s

50 participants --> 42 completed the study

8 were excluded --> early transfer --> university Hospitalpolicy


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Result

s


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Result

s


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Discussion

- Apparent reduction of severe medical complication and safety early

mobilization protocol on neurological scales and cerebral blood flow

- This study concur with other observational studies --> prolonged bed rest--> increased complication

- In line with AVERT II trial --> safety of early mobilization

- This study adds data to Cohrane Review comparing early mobilization vsstandard care


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- 6-7 days of bed rest --> theoretical worsening of perfussion in

hypoperfused tissue --> little evidence to support the hypothesis

- Sorbello et al : no statistically significance difference in

complication between two groups but found prolonged stay of

standard care group

- Langhorne et al : lower rate of complications of immobility in the

early active mobilization group --> sitting, standing, walking. This

study focused on head position

Discussion


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Discussion

Recent AVERT study shows early mobilization protocol moved patients out of bed

within 24 hr --> fastrack return to unassisted walking and improve functioal recovery.

This study has diffrerent end point

Keeping pstients in bed --> maintain cerebral perfussion pressure in the penumbraregion --> horizontal body and head position could increase intra cranial blood flow -->


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Study Limitation

Small Sample

Unequal drop out rate in treatment group

Primary outcome is not measured in blinded way

Transcranial doppler was performed in 60 % of

samples


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Conclusion

Apparent reduction in severe complication with early

mobilisation

No increase in total complication

No influence on neurological 3 month outcomes or on

cerebral blood flow

Larger trials is needed


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Thank You

Documents

Presentation 1st Journal Reading Thomas Purba MD