Very early versus delayed mobilisation after stroke.
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ABSTRACT:
SUBMITTER: Langhorne P
PROVIDER: S-EPMC6517132 | biostudies-literature | 2018 Oct
REPOSITORIES: biostudies-literature
Publications
Very early versus delayed mobilisation after stroke.
Langhorne Peter P Collier Janice M JM Bate Patricia J PJ Thuy Matthew Nt MN Bernhardt Julie J
The Cochrane database of systematic reviews 20181016
<h4>Background</h4>Very early mobilisation (VEM) is performed in some stroke units and recommended in some acute stroke clinical guidelines. However, it is unclear whether very early mobilisation independently improves outcome after stroke.<h4>Objectives</h4>To determine whether very early mobilisation (started as soon as possible, and no later than 48 hours after onset of symptoms) in people with acute stroke improves recovery (primarily the proportion of independent survivors) compared with us ...[more]
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Project description:ObjectivesWhile very early mobilisation (VEM) intervention for stroke patients was shown not to be effective at 3 months, 12 month clinical and economical outcomes remain unknown. The aim was to assess cost-effectiveness of a VEM intervention within a phase III randomised controlled trial (RCT).DesignAn economic evaluation alongside a RCT, and detailed resource use and cost analysis over 12 months post-acute stroke.SettingMulti-country RCT involved 58 stroke centres.Participants2104 patients with acute stroke who were admitted to a stroke unit.InterventionA very early rehabilitation intervention within 24 hours of stroke onset METHODS: Cost-utility analyses were undertaken according to pre-specified protocol measuring VEM against usual care (UC) based on 12 month outcomes. The analysis was conducted using both health sector and societal perspectives. Unit costs were sourced from participating countries. Details on resource use (both health and non-health) were sourced from cost case report form. Dichotomised modified Rankin Scale (mRS) scores (0 to 2 vs 3 to 6) and quality adjusted-life years (QALYs) were used to compare the treatment effect of VEM and UC. The base case analysis was performed on an intention-to-treat basis and 95% CI for cost and QALYs were estimated by bootstrapping. Sensitivity analysis were conducted to examine the robustness of base case results.ResultsVEM and UC groups were comparable in the quantity of resource use and cost of each component. There were no differences in the probability of achieving a favourable mRS outcome (0.030, 95% CI -0.022 to 0.082), QALYs (0.013, 95% CI -0.041 to 0.016) and cost (AUD1082, 95% CI -$2520 to $4685 from a health sector perspective or AUD102, 95% CI -$6907 to $7111, from a societal perspective including productivity cost). Sensitivity analysis achieved results with mostly overlapped CIs.ConclusionsVEM and UC were associated with comparable costs, mRS outcome and QALY gains at 12 months. Compared with to UC, VEM is unlikely to be cost-effective. The long-term data collection during the trial also informed resource use and cost of care post-acute stroke across five participating countries.Trial registration numberACTRN12606000185561; Results.
| S-EPMC6537993 | biostudies-literature
Project description:BackgroundProximal humerus fractures (PHFs) are among the commonest bony injuries and the majority of them can be managed non-surgically. The aim of our systematic review and meta-analysis was to compare the effectiveness and safety of early versus delayed mobilisation in conservatively treated PHFs.MethodsA literature search was performed in Medline, EMBASE and clinicaltrials.gov in Januray 2025 aiming to identify all randomised controlled trials (RCTs) comparing early versus delayed (conventional) mobilisation as part of the non-surgical management of PHFs. Primary outcomes were patient-reported function and pain at short-term (3 months), mid-term (6 months) and long-term (12 months) follow-up, and secondary outcomes included secondary fracture displacement and total complications. Meta-analyses produced mean differences (MDs) or standardised MDs (SMDs) for continuous outcomes and odds ratios (ORs) for binary outcomes, with 95% confidence intervals (CI). Certainty of evidence was assessed using the GRADE tool. Recommendations for clinical practice were given only based on results of high or moderate certainty of evidence.ResultsSix (6) RCTs were included that compared early mobilisation (EM; within one week from injury) to delayed mobilisation (DM; after 3 or 4 weeks of immobilisation) with a total of 470 patients with PHFs. There were no differences in patient-reported function (combined or Constant score) or pain between the EM and DM groups at any follow-up time points except for a significant difference in combined function scores favouring EM [SMD 0.4 CI (0.1,0.7), P = 0.006] at 3 months follow-up. There were no significant differences in the incidence of secondary fracture displacement and total complications in the two groups [OR 3.5 CI (0.7,18.2), P > 0.05, and OR 1.2 CI (0.5,2.9), P > 0.05, respectively]. All results were based on moderate or high strength of evidence. The most significant limitations of our study were the small number of pooled studies and inability to perform subgroup analyses for specific fracture types.ConclusionsOur meta-analysis of RCTs showed that commencement of mobilisation within one week from injury for non-surgically managed PHFs is safe and may confer short-term functional benefits compared to delayed mobilisation.
| S-EPMC11866563 | biostudies-literature
Project description:BackgroundTiming of surgery remains controversial in patients with infective endocarditis and stroke. Guidelines on infective endocarditis suggest delaying surgery for up to 4 weeks. However, with early heart failure due to progression of the infection or recurrent septic embolism, urgent surgery becomes imperative.MethodsOut of 688 patients who were surgically treated for left-sided infective endocarditis, 187 presented with preoperative neurological events. The date of cerebral stroke onset was documented in 147 patients. The patients were stratified according to timing of surgery: 61 in the early group (0-7 days) vs. 86 in the delayed group (>7 days). Postoperative neurological outcome was assessed by the modified Rankin Scale.ResultsPreoperative sepsis was more prevalent in patients with preoperative neurological complications (46.0% vs. 29.5%, p < 0.001). Patients with haemorrhagic stroke were operated on later (19.8% vs. 3.3%, p = 0.003). Postoperative cerebrovascular accidents were comparable between both groups (p = 0.13). Overall, we observed good neurological outcomes (p = 0.80) and a high recovery rate, with only 5% of cases showing neurological deterioration after surgery (p = 0.29). In-hospital mortality and long-term survival were not significantly different in the early and delayed surgery groups (log-rank, p = 0.22).ConclusionsEarly valve surgery in high-risk patients with infective endocarditis and stroke can be performed safely and is not associated with worse outcomes.
| S-EPMC10455129 | biostudies-literature
Project description:Background Although it is traditionally regarded as a single entity, perioperative stroke comprises 2 separate phenomena (early/intraoperative and delayed/postoperative stroke). We aimed to systematically evaluate incidence, risk factors, and clinical outcome of early and delayed stroke after cardiac surgery. Methods and Results A systematic review ( MEDLINE , EMBASE , Cochrane Library) was performed to identify all articles reporting early (on awakening from anesthesia) and delayed (after normal awakening from anesthesia) stroke after cardiac surgery. End points were pooled event rates of stroke and operative mortality and incident rate of late mortality. Thirty-six articles were included (174 969 patients). The pooled event rate for early stroke was 0.98% (95% CI 0.79% to 1.23%) and was 0.93% for delayed stoke (95% CI 0.77% to 1.11%; P=0.68). The pooled event rate of operative mortality was 28.8% (95% CI 17.6% to 43.4%) for early and 17.9% (95% CI 14.0% to 22.7%) for delayed stroke, compared with 2.4% (95% CI 1.9% to 3.1%) for patients without stroke ( P<0.001 for early versus delayed, and for perioperative stroke, early stroke, and delayed stroke versus no stroke). At a mean follow-up of 8.25 years, the incident rate of late mortality was 11.7% (95% CI 7.5% to 18.3%) for early and 9.4% (95% CI 5.9% to 14.9%) for delayed stroke, compared with 3.4% (95% CI 2.4% to 4.8%) in patients with no stroke. Meta-regression demonstrated that off-pump was inversely associated with early stroke (β=-0.009, P=0.01), whereas previous stroke (β=0.02, P<0.001) was associated with delayed stroke. Conclusions Early and delayed stroke after cardiac surgery have different risk factors and impacts on operative mortality as well as on long-term survival.
| S-EPMC6662344 | biostudies-literature
Project description:ObjectivesTo compared the effect of early antihypertensive treatment started within 24-48 h of stroke onset versus delaying treatment until day eight on reducing dependency or death.DesignMulticentre, randomised, open label trial.Setting106 hospitals in China between 13 June 2018 and 10 July 2022.Participants4810 patients (≥40 years) were enrolled with acute ischaemic stroke within 24-48 h of symptom onset and elevated systolic blood pressure between 140 mm Hg and <220 mm Hg.InterventionsPatients were randomly assigned to receive antihypertensive treatment immediately after randomisation (aimed at reducing systolic blood pressure by 10%-20% within the first 24 h and a mean blood pressure <140/90 mm Hg within seven days) or to discontinue antihypertensive medications for seven days if they were taking them, and then receive treatment on day 8 (aimed at achieving mean blood pressure <140/90 mm Hg).Main outcome measuresThe primary outcome was the combination of functional dependency or death (modified Rankin scale score ≥3) at 90 days. Intention to treat analyses were conducted.Results2413 patients were assigned to the early treatment group and 2397 were assigned to the delayed treatment group. Mean systolic blood pressure was reduced by 9.7% (from 162.9 mm Hg to 146.4 mm Hg) in the early treatment group and by 4.9% (from 162.8 mm Hg to 154.3 mm Hg) in the delayed treatment group within 24 h after randomisation (P for group difference <0.001). Mean systolic blood pressure was 139.1 mm Hg in the early treatment group and 150.9 mm Hg in the delayed treatment group on day seven (P for group difference <0.001). Additionally, 54.6% of patients in the early treatment group and 22.4% in the delayed treatment group had blood pressure of less than 140/90 mm Hg (P<0.001 for group difference) on day seven. At day 90, 289 trial participants (12.0%) in the early treatment group, compared with 250 (10.5%) in the delayed treatment group, had died or experienced a dependency (odds ratio 1.18 (95% confidence interval 0.98 to 1.41), P=0.08). No significant differences in recurrent stroke or adverse events were reported between the two groups.ConclusionsAmong patients with mild-to-moderate acute ischaemic stroke and systolic blood pressure between 140 mm Hg and <220 mm Hg who did not receive intravenous thrombolytic treatment, early antihypertensive treatment did not reduce the odds of dependency or death at 90 days.Trial registrationClinicalTrials.gov Identifier NCT03479554.
| S-EPMC10561001 | biostudies-literature
Project description:Rotator cuff tears are a common cause for pain and reduced function. Tears of the tendons of the cuff can be a result of a degenerative process or as a consequence of trauma. Management of cuff tears are surrounded by controversy from indications for surgical management to rehabilitation protocol post-surgical repair. The aim of post surgical rehabilitation is to improve functional outcome, reduce pain and promote tendon healing. In the case of rotator cuff repair, rehabilitation can be broadly divided into early passive range of motion (EPM) and delayed range of motion (DRM). The EPM regime is defined by minimal immobilisation of the shoulder and passive mobilisation of the joint within the first post-operative period. In contrast, DRM immobilises the shoulder joint up to six weeks post-operatively. Proponents of EPM state various advantages of their rehabilitation protocol including improved range of motion and earlier return to normal activities of daily living. However, there has also been concern that this rehabilitation regime may result in an increased rate of re-rupture. Since this is a highly controversial issue, various high quality literature have been published looking to clarify which regime is best following rotator cuff surgery. Reviewing these articles, it appears that there is an increase rate of re-tear of the repaired rotator cuff tendon when the EPM regime is employed. Statistical significance however was limited by small sample sizes. Range of motion post-repair also appears to be associated with post-operative rehabilitation regime. As expected, the EPM regime has been shown to improve range of motion post-repair. Despite this, literature reports patients managed with the DPM showed a statistically better patient reported outcome measure. We conclude that based on the evidence we currently have, early range of motion post rotator cuff repair is related with an increase risk of re-tear. The DPM regime reduces this risk with the possible complication of reduced range of shoulder movement. This problem is thought to be an easier clinical issue to deal with compared to re-rupture of the repaired rotator cuff tendon. There is however lack of data to achieve statistical significance in most of these analysis. There is a definite need for a large, multi-centre single blinded randomised controlled trial to further shed light on this controversial topic.
| S-EPMC6382997 | biostudies-literature
Project description:BackgroundPancreatic ductal adenocarcinoma (PDAC) is a highly aggressive tumor showing a tendency for early recurrence, even after curative resection. Although adjuvant treatment improves survival, it is unclear whether early adjuvant treatment initiation yields better outcomes in patients with PDAC.MethodsWe retrospectively enrolled 113 patients who underwent chemotherapy or chemoradiotherapy after curative resection of PDAC: Fifty-six and 57 patients were in the early and delayed groups, respectively based on the median time of treatment initiation (35 days [range, 20-83 days]).ResultsPatient baseline characteristics were comparable in both groups, except for grade III or IV postoperative complications (5.4% in the early group vs. 22.8% in the delayed group). With a median 20.3-month follow-up, the overall survival (OS) and disease-free survival (DFS) times were 29.5 and 14.7 months, respectively. The early group had significantly prolonged OS (39.1 vs. 21.1 months, p = 0.018) and DFS (18.8 vs. 10.0 months, p = 0.034), compared to the delayed group. Among 71 patients who completed planned adjuvant treatment, patients in the early group tended to have longer, though not statistically significant, OS and DFS times than those in the delayed group. In 67 patients without postoperative complications, patients in the early group had longer OS (42.8 vs. 20.5 months, p = 0.002) and DFS (19.6 vs. 9.1 months, p = 0.005) than those in the delayed group. By multivariate analysis, incompletion of treatment (hazard ratio [HR]: 4.039, 95% confidence interval [CI]: 2.334-6.992), delayed treatment initiation (HR: 1.822, 95% CI: 1.081-3.070), and positive angiolymphatic invasion (HR: 2.116, 95% CI: 1.160-3.862) were significantly associated with shorter OS.ConclusionsAdjuvant treatment should be delivered earlier and completed for better outcomes in resected PDAC patients, especially without postoperative complications.
| S-EPMC5354454 | biostudies-literature
Project description:ObjectivesThis is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of early versus delayed timing of vitrectomy after open-globe injury on visual outcomes.
| S-EPMC11605792 | biostudies-literature
Project description:BackgroundRecent trials of acute secondary prevention in patients with minor ischemic stroke or transient ischemic attack (TIA) have demonstrated high rates of early recurrence within days of the initial event. Identifying clinical features associated with early recurrence may guide focused management.MethodsUsing logistic regression applied to the data of the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial, we evaluated what baseline clinical factors predict outcome events occurring within 7 days of randomization.ResultsIn the POINT trial, 181 subjects (3.7%) had early recurrence, defined as primary outcome events within 7 days of trial entry, whereas only 100 outcome events occurred over the remainder of the 90 day trial. Protective effects of dual antiplatelet therapy with clopidogrel plus aspirin were seen only as a reduction in these early recurrences, without any impact on later events. In univariate analysis, systolic blood pressure, diastolic blood pressure, serum glucose, initial carotid imaging results, study cohort (minor stroke or TIA), and treatment assignment were significantly associated with early recurrence. Multivariate logistic regression analysis identified a number of factors with significant independent associations with early recurrence, including carotid stenosis or occlusion (Odds Ratio [OR] 2.77; 95% confidence interval [CI] 1.78-4.31), cohort (minor stroke versus TIA) (OR 1.86; 95% CI 1.33-2.58), race (OR 1.57; 95% CI 1.10-2.25), baseline statin use (OR 0.68; 95% CI 0.49-0.95), systolic blood pressure (OR 1.10; 95% CI 1.03-1.18), serum glucose (OR 1.03; 95% CI 1.01-1.05), and age (OR 1.02; 95% CI 1.00-1.03). Receiver Operator Characteristic (ROC) analysis showed a 70% accuracy of the resulting logistic model in predicting early recurrence.ConclusionsEarly recurrence is high, and is concentrated in the first 7 days, in patients with minor stroke or TIA. A number of baseline clinical factors, including carotid disease, presentation with minor stroke rather than TIA, race, absence of statin usage, systolic blood pressure, and serum glucose, are independently associated with early event recurrence in the POINT trial population.
| S-EPMC9107185 | biostudies-literature
Project description: Not available
| S-EPMC6984627 | biostudies-literature