AMOBES (Active Mobility Very Early After Stroke)

Abstract

In the early stage after stroke, within the first 2 weeks, physical therapy (PT) has 2 main goals: prevent immobilityrelated events and stimulate motor control recovery. However, the amount of PT to provide and the time after stroke for provision remain unclear.The organization of care in multidisciplinary stroke units has reduced the risk of death and dependency after stroke, with early mobilization and rehabilitation having an important role.1-3 Very early mobilization (VEM) was defined by the AVERT group (A Very Early Rehabilitation Trial): within the first 24 hours, focusing on out-of-bed activity (sitting, standing, walking), provided at least 3× more than usual care, by physical therapists or nurses. VEM has been found safe and feasible, 4 with a significant positive effect on recovery of walking 50 m unassisted, good functional prognosis on Barthel index at 3 months, 5 and for the frequency of severe complications. 6 Hemorrhagic stroke patients showed a better level of function (walking >15.24 m). 7 The recent European recommendations 8 and those from the American Stroke Association 9 promote VEM, although how early and how much a patient should be mobilized remains controversial. Some negative impact of early (<24 hours) versus delayed (<48 hours) physical rehabilitation has been reported, with increased risk of death. 10Background and Purpose-Intensive physical therapy (PT) facilitates motor recovery when provided during a subacute stage after stroke. The efficiency of very early intensive PT has been less investigated. We aimed to investigate whether intensive PT conducted within the first 2 weeks could aid recovery of motor control. Methods-This multicentre randomized controlled trial compared soft PT (20-min/d apart from respiratory needs) and intensive PT (idem+45 minutes of intensive exercises/day) initiated within the first 72 hours after a first hemispheric stroke. The primary outcome was change in motor control between day (D) 90 and D0 assessed by the Fugl-Meyer score. Main secondary outcomes were number of days to walking 10 m unassisted, balance, autonomy, quality of life, and unexpected medical events. All analyses were by intent to treat. Results-We could analyze data for 103 of the 104 included patients (51 control and 52 experimental group; 64 males; median age overall 67 [interquartile range 59-77], 67 right hemispheric lesions, 80 ischemic lesions, National Institutes of Health Stroke Scale score ≥8 for 82%). Fugl-Meyer score increased over time (P<0.0001), with no significant effect of treatment (P=0.29) or interaction between treatment and time (P=0.40). The median change in score between D90 and D0 was 27.5 (12-40) and 22.0 (12-56) for control and experimental groups (P=0.69). Similar results were found for the secondary criteria. Conclusions-Very early after stroke, intensive exercises may not be efficient in improving motor control. This conclusion may apply to mainly severe stroke. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01520636.

Early Rehabilitation After Stroke: a Narrative Review

“…This small trial ( n = 56) was underpowered and therefore inconclusive, but in light of the AVERT trial, it adds to the concern that mobilization within 24 h might be detrimental. Another multicenter RCT, AMOBES (Active Mobility Very Early After Stroke) [50], compared 20 min per day of “soft” physical therapy (PT) (passive range-of-motion exercises aimed at preventing immobility-related complications) with soft PT plus 45 min of active intensive exercises, both commencing within 72 h of stroke. This trial found no difference in motor impairment at 90 days, as measured by the Fugl-Meyer Motor Scale (FMMS).…”

Aerobic Training and Mobilization Early Post-stroke: Cautions and Considerations

“…In a subsequent study, 104 people with severe stroke were randomized to soft physiotherapy (20 min per day) vs. intensive physiotherapy (soft physiotherapy plus 45 min of intensive exercise/day) initiated within the first 72 h after stroke for 2 weeks (10 sessions) (191). Similar to the meta-analysis discussed above, no between-group differences were reported in mRS score, Functional Independence Measurement, mobility, change in Postural Assessment Scale for Stroke, or quality-of-life measure after 90 days.…”

Early Mobilization of Mild-Moderate Intracerebral Hemorrhage Patients in a Stroke Center: A Randomized Controlled Trial

“…4-6 Very early mobilization with higher-frequency sessions in an out-of-bed mobility-based training protocol within 24 hours of stroke onset may be associated with a worse outcome at 3 months poststroke, 7,8 but most studies examined the beneficial effects of early mobilization commencing within 24 to 72 hours of stroke. 4,9-12 However, early mobilization within 24 to 72 hours might also worsen any poststroke hypertension and increase the risk of rebleeding, resulting in early deterioration after acute intracerebral hemorrhage (ICH). 13 Most clinicians harbor greater concerns about the early mobilization of patients with hemorrhagic rather than ischemic stroke.…”

“…7 However, the AVERT protocol was characterized not only by early mobilization within 24 hours of stroke onset but also by a significantly greater frequency (≥3 times) and total duration of mobilization sessions than the usual care protocol. 7 Because there is insufficient evidence to recommend intensive training, such as longer session duration or higher frequency intervention within the first few days of stroke, 11 and considering the staff workload involved with higher frequency intervention, it is important to understand whether early mobilization improves outcomes, even if intervention time and daily session duration are similar to those in standard care. Therefore, we conducted a study with stringent selection criteria and rigorously controlled the intensity of early mobilization to determine the merits of early mobilization in poststroke rehabilitation, specifically in ICH patients during the acute period.…”