Effects of not early standing within neurcognitive treatment after stroke

Background: SPREAD guidelines (1) recommend early mobilization in acute stroke care, in order to prevent secondary and tertiary damages caused by immobilization. They propose standing as a short-term goal since the acute phase. According to SPREAD guidelines, the achievement of early standing and walking enhances the rate of discharge to the patient’s own home and ensures a lower degree of disabilities. There is, however, a lack of agreement in terms of what ‘early mobilization’ means, and optimal timing of standing and walking after a stroke remains poorly defined. Aim: This study sets out to determine whether a rehabilitative treatment which contemplates not early standing and walking, such as a neurocognitive approach, influences the functional outcome of patients after a stroke. Materials and methods: A retrospective observational study was conducted. Fifty patients [26 female and 24 male - mean age 69.6 yrs, range 34-91, s 15.16 – median days after stroke 10, interquartile range (IQR) 5], affected by a sub-acute ischemic or haemorrhagic stroke, admitted to Rehabilitation Unit of San Paolo Hospital in Milan, were consecutively enrolled over a two-year period. Each patient has undergone rehabilitative treatment according to a neurocognitive approach, which did not provide early standing and walking [median hospitalization days 41.5, IQR 35]. The Barthel Index (2) was recorded at the admission (BI-in) and the discharge (BI-out) to assess the disability degree of each patient and to evaluate the functional gain provided by rehabilitative treatment. Outcome measures were subjected to a non-parametric test (Wilcoxon signed-rank test). Results: BI-in median was 55 [IRQ 50], BI-out median was 90 [IQR 25]. This result was statistically significant: Z -6.155, p <0.0001 (2-tailed), r 0.87 (large effect size according to Cohen’s criteria). Discussion: Our neurocognitive treatment, with not-early standing and walking, had a good functional outcome without secondary and tertiary damages. SPREAD guidelines recommend early mobilization after stroke, but provide few specific practice directives. It is important to point out that early mobilization does not necessarily imply early standing and walking. This concept does not clearly emerge from the SPREAD guidelines. On the other hand, very early and intense activities could determine an overload of the damaged neural circuits and enhance glutamate receptor-mediated excitotoxicity during an early post-lesional vulnerable period (3). Conclusion: Our study suggests that not-early standing and walking are not necessarily associated with a poor functional outcome. Finally, the timing of standing and walking is still controversial. References: 1 - http://www.spread.it/files/Raccomandazioni_Sintesi_SPREAD2012.pdf 2 - Mahoney FI, Barthel DW. Functional evaluation: the Barthel index. Md State Med J. 1965 Feb;14:61-5 3 - Humm JL, Kozlowski DA, James DC, et al. Use-dependent exacerbation of brain damage occurs during an early post-lesion vulnerable period. Brain Res 1998;783:286–92.