Rehabilitation may work best 60-90 days after stroke

I disagree.

VEM(Very Early Mobilization) may prevent complications with a high risk of causing harm such as deep vein thrombosis, pulmonary embolism, contractures, infections, sores, muscle atrophy and deterioration in cardiorespiratory function. The complications associated with immobility were shown to be responsible for 51 % of deaths in patients with cerebral infarction.⁹ 

Early Mobilisation Following Stroke has the above lines which I consider to be vastly more important to occur than a later rehab start. But I'm not medically trained so don't listen to me.

 So what is the fucking time to start rehab? Where the hell is the protocol on this? You don't want your doctors and therapists just flailing in the dark on what to do.

 

Rehabilitation may work best 60-90 days after stroke

Stroke survivors may respond best to rehabilitation programs administered 60 to 90 days after the stoke, a clinical trial suggests.

For the study, researchers randomized 72 stroke patients (mean age 62.8 years) into one of four groups: acute rehabilitation delivered up to 30 days post-stroke (n=16), subacute rehabilitation delivered 2 to 3 months after the stroke (n=17), chronic rehabilitation initiated at least 6 months post-stroke (n=20), or a control group that received standard rehabilitation. All three intervention groups received 20 extra hours of self-selected, task specific motor therapy in addition to standard motor rehabilitation provided to the control group.

The primary endpoint of the study was upper extremity impairment measured by the Action Research Arm Test (ARAT) at one year post-stroke.

People in the subacute rehabilitation group had significantly better motor function based on ARAT scores than the control group (ARAT difference +6.87) at one year, the study team reports in the Proceedings of the National Academy of Sciences.

The acute rehab group also had significantly better motor function, although the difference was less pronounced (ARAT difference +5.25). The chronic rehabilitation group, however, didn't fare significantly better than the control group in motor function tests at one year, the analysis found. "The reason that specific timing is important is because, in animal models of stroke, we know that there is a series of processes that occur in the brain after stroke: first some death of cells surrounding the stroke area, and then next some sprouting of new connections, as though the brain is attempting to recover," said study co-author Elissa Newport, director of the Center for Brain Plasticity and Recovery at Georgetown University Medical Center and MedStar National Rehabilitation Hospital in Washington, D.C. "But we didn't know whether that second process occurs in humans as well, or when it happens," Newport said by email. Results of the study suggest that this process does indeed occur in people, and that the window is around 60 to 90 days after a stroke. "That brain recovery process is short-lived, and ideally any rehabilitation training must meet it, synergistically, at the perfect moment in order to produce and maintain the best connections and achieve the best recovery," Newport said. Outside of this critical time period, rehabilitation aimed at motor function recovery may not be as effective at producing new connections in the brain, Newport added. Beyond its small size, other limitations of the study include the lack of neurophysiologic and imaging studies to more fully assess stroke recovery, the researchers note. Most patients currently don't receive intensive rehabilitation within this 60-to-90 day window because Medicare and other insurers don't extend coverage to continue outpatient rehabilitation for this many days after a stroke, Newport said.

"We hope that our results, if supported by additional and larger clinical trials, can encourage Medicare and other insurance coverages to include intensive rehabilitation at the times that our scientific findings show the best outcomes," Newport said.

—Lisa Rapaport

To read more, click here

 

Very Early Versus Delayed Mobilization After Stroke

My God, have you got the understanding of what is occurring wrong. The neuronal cascade of death

is still occurring  during this early rehab. And you didn't know about that or measure its occurrence?  

I don't care how influential Julie Bernhardt is in stroke circles, she's wrong here, missing what is occurring during the neuronal cascade of death.

 

 

Very Early Versus Delayed Mobilization After Stroke

Julie Bernhardt

,

Janice M. Collier

,

Patricia J. Bate

,

Matthew N.T. Thuy

,

Peter Langhorne

Originally published16 May 2019https://doi.org/10.1161/STROKEAHA.119.024502Stroke. 2019;50:e178–e179

Objective

The objective of this review is to determine whether very early mobilization (helping a patient get out of bed within 48 hours after stroke onset) improves or harms recovery after stroke.¹

Methods

We systematically searched the Cochrane Stroke Group trials register, 19 English language electronic databases, Wanfang data (Chinese language medical database), relevant ongoing trials and research registers, reference lists, and contacted researchers in the field.
We selected unconfounded randomized controlled trials and compared mobilization commencing within 48 hours with usual stroke care.
One author eliminated obviously irrelevant records; 2 authors independently selected English language trials, extracted data, assessed risk of bias, and applied the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach to the quality of evidence.

Main Results

Seventy-four full papers were assessed. Nine trials were included (n=2958). Participants were median age 68 years; 52% were males; 0% to 20% had intracerebral hemorrhage; and stroke severity was typically moderate. Very early mobilization participants started mobilization median 18.5 hours (interquartile range, 13.1−43 hours) after stroke compared with 33.3 hours (interquartile range, 22.5−71.5 hours) in usual care. Very early mobilization did not increase the number of people who survived or made a good recovery after their stroke (odds ratio, 1.08; 95% CI, 0.92−1.26; Figure).

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Figure. Death or poor outcome at end of scheduled follow-up. M-H indicates Mantel-Haenszel test; and VEM, very early mobilization.

Conclusions

Commencing mobilization earlier after stroke did not improve death or poor outcome. Possible risks within 24 hours need clarifying. Further research to determine the optimal dose and timing of mobilization after acute stroke is needed.

Very Early Initiation Reduces Benefits of Poststroke Rehabilitation Despite Increased Corticospinal Projections

My God, have you got the conclusion wrong. The neuronal cascade of death

is still occurring  during this early rehab. And you didn't know about that or measure its occurrence? 

Very Early Initiation Reduces Benefits of Poststroke Rehabilitation Despite Increased Corticospinal Projections

Show all authors

Naohiko Okabe, PhD, Naoyuki Himi, PhD, Emi Nakamura-Maruyama, PhD, ...

First Published May 29, 2019 Research Article

https://doi.org/10.1177/1545968319850132

Article information

Abstract

Background. Although the effect of rehabilitation is influenced by aspects of the training protocol, such as initiation time and intensity of training, it is unclear whether training protocol modifications affect the corticospinal projections.
Objective. The present study was designed to investigate how modification of initiation time (time-dependency) and affected forelimb use (use-dependency) influence the effects of rehabilitation on functional recovery and corticospinal projections.  
Methods. The time-dependency of rehabilitation was investigated in rats forced to use their impaired forelimb immediately, at 1 day, and 4 days after photothrombotic stroke. The use-dependency of rehabilitation was investigated by comparing rats with affected forelimb immobilization (forced nonuse), unaffected forelimb immobilization (forced use), and a combination of forced use and skilled forelimb training beginning at 4 days after stroke.  
Results. Although forced use beginning 1 day or 4 days after stroke caused significant functional improvement, immediate forced limb use caused no functional improvement. On the other hand, a combination of forced use and skilled forelimb training boosted functional recovery in multiple tasks compared to simple forced use treatment. Histological examination showed that no treatment caused brain damage. However, a retrograde tracer study revealed that immediate forced use and combination training, including forced use and skilled forelimb training, increased corticospinal projections from the contralesional and ipsilesional motor cortex, respectively.
Conclusions. These results indicate that although both very early initiation time and enhanced skilled forelimb use increased corticospinal projections, premature initiation time hampers the functional improvement induced by poststroke rehabilitation.

Keywords stroke, rehabilitation, constraint-induced movement therapy, corticospinal projection, motor function, time dependency, use dependency

Introduction

Rehabilitation is the most commonly used treatment for chronic stroke patients due to many evidences demonstrating its safety and effectiveness.¹ However, functional recovery is often incomplete even when intensive rehabilitation is carried out. Although preclinical studies showed neurorestorative effects of newly developing therapies such as stem cell therapy² or anti-NogoA immunotherapy,³ none of them has been approved in clinical setting. Thus, improving effectiveness of rehabilitation remains an essential strategy to attain better recovery after stroke.⁴ Since effect of rehabilitation is affected by modification of rehabilitation protocol as well as patient’s age, comorbidity, and size and location of infarct, guideline to design optimal rehabilitation protocol is required to maximize their efficacy. Nevertheless, it has not been accomplished due to lack of sufficient evidences.
Neural plasticity is heightened during the critical period of the early poststroke recovery phase. And the greatest gains in recovery occur in this period through activity-dependent neural network remodeling.⁵ Therefore, there is a general consensus that more intensive rehabilitation initiated in earlier recovery phase would cause better functional outcome, and which was actually supported by many clinical trials.^6,7 For example, a clinical trial that compared the functional improvement after constraint-induced movement therapy (CIMT) initiated in early (3-9 months after stroke) and delayed phase (15-21 months after stroke) demonstrated that early CIMT induces greater functional improvement (EXCITE Stroke Trial).⁸ However, some important questions remain to be clarified. Although it is generally accepted that early rehabilitation caused better functional outcome than later one, how early rehabilitation should begin is still controversial because previous studies demonstrated very early rehabilitation has a potential to increase damage to the ischemic penumbra.⁹ Recent big multicenter randomized controlled trial also reported that the higher dose, very early mobilization protocol was associated with a reduction in the odds of a favorable outcome at 3 months.¹⁰ Similarly, in the regard of training intensity, whereas dose-response relationship has been repeatedly evaluated by comparing total time for therapy,^6,7 a single-blind phase II trial of CIMT (Very Early Constraint-Induced Movement during Stroke Rehabilitation [VECTORS] study) reported that higher intensity CIMT resulted in less motor improvement at 90 days compared to lower intensity CIMT and traditional upper extremity therapy,¹¹ suggesting that too intense training could deteriorate functional recovery. To determine proper rehabilitation regimen, understanding of biological events underlying unfavorable effect induced by too early and intensive training is necessary. However, although previous studies have demonstrated that the integrity and plasticity of corticospinal projections are fundamental for rehabilitation-induced functional recovery after stroke,^12-14 it is not known how modifications of the rehabilitation protocol affect these projections.
The purpose of the present study was to examine how modifications of the rehabilitation protocol, and in particular of time of initiation (time dependency) and affected forelimb use (use dependency), impact functional recovery by rehabilitative training after severe cortical stroke and how corticospinal projections is also affected by these modifications.

Very Early Initiation Reduces Benefits of Poststroke Rehabilitation Despite Increased Corticospinal Projections

Whatever the fuck corticospinal projections are and with no protocol here this is useless. 

Very Early Initiation Reduces Benefits of Poststroke Rehabilitation Despite Increased Corticospinal Projections 

Show all authors

Naohiko Okabe, PhD, Naoyuki Himi, PhD, Emi Nakamura-Maruyama, PhD, ...

First Published May 29, 2019 Research Article

https://doi.org/10.1177/1545968319850132

Article information

Abstract

Background. Although the effect of rehabilitation is influenced by aspects of the training protocol, such as initiation time and intensity of training, it is unclear whether training protocol modifications affect the corticospinal projections.  
Objective. The present study was designed to investigate how modification of initiation time (time-dependency) and affected forelimb use (use-dependency) influence the effects of rehabilitation on functional recovery and corticospinal projections.  
Methods. The time-dependency of rehabilitation was investigated in rats forced to use their impaired forelimb immediately, at 1 day, and 4 days after photothrombotic stroke. The use-dependency of rehabilitation was investigated by comparing rats with affected forelimb immobilization (forced nonuse), unaffected forelimb immobilization (forced use), and a combination of forced use and skilled forelimb training beginning at 4 days after stroke.  
Results. Although forced use beginning 1 day or 4 days after stroke caused significant functional improvement, immediate forced limb use caused no functional improvement. On the other hand, a combination of forced use and skilled forelimb training boosted functional recovery in multiple tasks compared to simple forced use treatment. Histological examination showed that no treatment caused brain damage. However, a retrograde tracer study revealed that immediate forced use and combination training, including forced use and skilled forelimb training, increased corticospinal projections from the contralesional and ipsilesional motor cortex, respectively.  
Conclusions. These results indicate that although both very early initiation time and enhanced skilled forelimb use increased corticospinal projections, premature initiation time hampers the functional improvement induced by poststroke rehabilitation.

Keywords stroke, rehabilitation, constraint-induced movement therapy, corticospinal projection, motor function, time dependency, use dependency

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High intensity physical rehabilitation later than 24 hours post stroke is beneficial in patients: A Pilot Randomized Controlled Trial (RCT) Study in mild to moderate ischemic Stroke

Andrew Marr of the UK however blames high-intensity exercise for his stroke.

If you can do high intensity training that soon you had a small stroke.

Can too much exercise cause a stroke?

You might want to consult your doctor on this. Bet s/he doesn't even know about Andrew Marr.
 

High intensity physical rehabilitation later than 24 hours post stroke is beneficial in patients: A Pilot Randomized Controlled Trial (RCT) Study in mild to moderate ischemic Stroke

• ¹Beijing Luhe Hospital, Capital Medical University, China
• ²Wayne State University School of Medicine, United States

Objective: Very early mobilization was thought to contribute to beneficial outcomes in stroke-unit care, but the optimal intervention strategy including initiation time and intensity of mobilization are unclear. In this study, we sought to confirm the rehabilitative effects of different initiation times (24 vs. 48 h) with different mobilization intensities (routine or intensive) in ischemic stroke patients within 3 groups.
Materials and Methods: We conducted a randomized and controlled trial with a blinded follow-up assessment. Patients with ischemic stroke, first or recurrent, admitted to stroke unit within 24 hours after stroke onset were recruited. Eligible subjects were randomly assigned (1:1:1) to 3 groups: Early Routine Mobilization in which patients received <1.5 h/d out-of-bed mobilization within 24-48 h after stroke onset, Early Intensive Mobilization in which patients initiated ≥3h/d mobilization at 24-48 h after the stroke onset, and Very Early Intensive Mobilization in which patients received≥3h/d mobilization within 24 h. The modified Rankin Scale score of 0-2 was used as the primary favorable outcome.
Results: We analyzed 248 of the 300 patients (80 in Early Routine Mobilization, 82 in Very Early Intensive Mobilization and 86 in Early Intensive Mobilization), with 52 dropping out (20 in Early Routine Mobilization, 18 in Very Early Intensive Mobilization and 14 in Early Intensive Mobilization). Among the three groups, the Early Intensive Mobilization group had the most favorable outcomes at 3-month follow-up, followed by patients in the Early Routine Mobilization group. Patients in Very Early Intensive Mobilization received the least odds of favorable outcomes. At 3 month follow up, 53.5%, (n=46 ) of patients with Early Intensive Mobilization showed a favorable outcome (modified Rankin Scale 0-2)(p=0.041) as compared to 37.8% (n=31) of patients in the Very Early Intensive Mobilization.
Conclusions: Post-stroke rehabilitation with high intensity physical exercise at 48 h may be beneficial. Very Early Intensive Mobilization did not lead to a favorable outcome at 3 months. Trial registration: ChiCTR-ICR-15005992.

Keywords: Acute care, ischemic stroke, early mobilization., Intensity, Rehabilitation

Received: 29 Nov 2018; Accepted: 28 Jan 2019.

Edited by:
Nicola Smania, University of Verona, Italy

Reviewed by:
Alessandro Picelli, University of Verona, Italy
Paolo Tonin, Sant'Anna Institute, Italy  

Copyright: © 2019 Tong, Cheng, Rajah, Duan, Cai, Zhang, Du, Geng and Ding. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Prof. Yuchuan Ding, Wayne State University School of Medicine, Detroit, United States, yding@med.wayne.edu

high-dose, very early mobilization (within 24 hours of stroke) can reduce the odds of a favorable outcome at three months

I can't find the research referred to to see what they did wrong. But my assumptions are as follows;

1. They did no objective damage diagnosis to start with. Thus making this non-repeatable.

2. They didn't measure the neuronal cascade of death as it occurred.

3. They used the subjective Rankin scale to incorrectly measure outcomes.

high-dose, very early mobilization (within 24 hours of stroke) can reduce the odds of a favorable outcome at three months

 According to AHA/ASA stroke rehab & recovery guidelines, high-dose, very early mobilization (within 24 hours of stroke) can reduce the odds of a favorable outcome at three months and is not recommended.http://spr.ly/6014EP6qu 

Very early versus delayed mobilisation after stroke

Well fuck, still no protocols on this and obviously still doing nothing on first day interventions.  My 31 ideas on hyperacute therapy I'm going to insist my doctor give me during the first week,
even without further research or real clinical trials. I will take the chance that more benefits accrue than danger by using these. But run them by your doctor. No knowledge of any of them and you need to fire that doctor immediately, practicing medicine with no knowledge.  Does no one in stroke read/implement any research suggesting interventions in the first day?  Or is everyone in stroke so fucking lazy that they are waiting for SOMEONE ELSE TO SOLVE THE PROBLEM?

Like your 10 million yearly stroke survivors? Have your patients solve their own problems?

Very early versus delayed mobilisation after stroke

Cochrane Systematic Review - Intervention Version published: 16 October 2018 see what's new

• New search

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• Peter Langhorne
• Janice M Collier
• Patricia J Bate
• Matthew NT Thuy
• Julie Bernhardt

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Abstract

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Background

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.

Objectives

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 usual care.

Search methods

We searched the Cochrane Stroke Group Trials Register (last searched 31 July 2017). We also systematically searched 19 electronic databases including; CENTRAL; 2017, Issue 7 in the Cochrane Library (searched July 2017), MEDLINE Ovid (1950 to August 2017), Embase Ovid (1980 to August 2017), CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to August 2017) , PsycINFO Ovid (1806 to August 2017), AMED Ovid (Allied and Complementary Medicine Database), SPORTDiscus EBSCO (1830 to August 2017). We searched relevant ongoing trials and research registers (searched December 2016), the Chinese medical database, Wanfangdata (searched to November 2016), and reference lists, and contacted researchers in the field.

Selection criteria

Randomised controlled trials (RCTs) of people with acute stroke, comparing an intervention group that started out‐of‐bed mobilisation within 48 hours of stroke, and aimed to reduce time‐to‐first mobilisation, with or without an increase in the amount or frequency (or both) of mobilisation activities, with usual care, where time‐to‐first mobilisation was commenced later.

Data collection and analysis

Two review authors independently selected trials, extracted data, assessed risk of bias, and applied the GRADE approach to assess the quality of the evidence. The primary outcome was death or poor outcome (dependency or institutionalisation) at the end of scheduled follow‐up. Secondary outcomes included death, dependency, institutionalisation, activities of daily living (ADL), extended ADL, quality of life, walking ability, complications (e.g. deep vein thrombosis), patient mood, and length of hospital stay. We also analysed outcomes at three‐month follow‐up.

Main results

We included nine RCTs with 2958 participants; one trial provided most of the information (2104 participants). The median (range) delay to starting mobilisation after stroke onset was 18.5 (13.1 to 43) hours in the VEM group and 33.3 (22.5 to 71.5) hours in the usual care group. The median difference within trials was 12.7 (4 to 45.6) hours. Other differences in intervention varied between trials; in five trials, the VEM group were also reported to have received more time in therapy, or more mobilisation activity.
Primary outcome data were available for 2542 of 2618 (97.1%) participants randomized and followed up for a median of three months. VEM probably led to similar or slightly more deaths and participants who had a poor outcome, compared with delayed mobilisation (51% versus 49%; odds ratio (OR) 1.08, 95% confidence interval (CI) 0.92 to 1.26; P = 0.36; 8 trials; moderate‐quality evidence). Death occurred in 7% of participants who received delayed mobilisation, and 8.5% of participants who received VEM (OR 1.27, 95% CI 0.95 to 1.70; P = 0.11; 8 trials, 2570 participants; moderate‐quality evidence), and the effects on experiencing any complication were unclear (OR 0.88; 95% CI 0.73 to 1.06; P = 0.18; 7 trials, 2778 participants; low‐quality evidence). Analysis using outcomes collected only at three‐month follow‐up did not alter the conclusions.
The mean ADL score (measured at end of follow‐up, with the 20‐point Barthel Index) was higher in those who received VEM compared with the usual care group (mean difference (MD) 1.94, 95% CI 0.75 to 3.13, P = 0.001; 8 trials, 9 comparisons, 2630/2904 participants (90.6%); low‐quality evidence), but there was substantial heterogeneity (93%). Effect sizes were smaller for outcomes collected at three‐month follow‐up, rather than later.
The mean length of stay was shorter in those who received VEM compared with the usual care group (MD ‐1.44, 95% CI ‐2.28 to ‐0.60, P = 0.0008; 8 trials, 2532/2618 participants (96.7%); low‐quality evidence). Confidence in the answer was limited by the variable definitions of length of stay. The other secondary outcome analyses (institutionalisation, extended activities of daily living, quality of life, walking ability, patient mood) were limited by lack of data.
Sensitivity analyses by trial quality: none of the outcome conclusions were altered if we restricted analyses to trials with the lowest risk of bias (based on method of randomization, allocation concealment, completeness of follow‐up, and blinding of final assessment), or information about the amount of mobilisation.
Sensitivity analysis by intervention characteristics: analyses restricted to trials where the mean VEM time‐to‐first mobilisation was less than 24 hours, showed an odds of death of 1.35 (95% CI 0.99 to 1.83; P = 0.06; I² = 25%; 5 trials). Analyses restricted to the trials that clearly reported a more prolonged out‐of‐bed activity showed a similar primary outcome (OR 1.14; 0.96 to 1.35; P = 0.13; I² = 28%; 5 trials), and odds of death (OR 1.27; 0.93 to 1.73; P = 0.13; I² = 0%; 4 trials) to the main analysis.
Exploratory network meta‐analysis (NMA): we were unable to analyze by the amount of therapy, but low‐quality evidence indicated that time‐to‐first mobilisation at around 24 hours was associated with the lowest odds of death or poor outcome, compared with earlier or later mobilisation.

Authors' conclusions

VEM, which usually involved first mobilisation within 24 hours of stroke onset, did not increase the number of people who survived or made a good recovery after their stroke. VEM may have reduced the length of stay in hospital by about one day, but this was based on low‐quality evidence. Based on the potential hazards reported in the single largest RCT, the sensitivity analysis of trials commencing mobilisation within 24 hours, and the NMA, there was concern that VEM commencing within 24 hours may carry an increased risk, at least in some people with stroke. Given the uncertainty around these effect estimates, more detailed research is still required.(Well, write up a protocol for what is currently known. Waiting for perfection allows massive numbers of neurons to continue dying every day.)

AVERT: Very Early Mobilization Harmful in Stroke

Something for your doctor to chew on. I wonder how the patients were chosen to be included in the trial? Something about this does not sound right.
http://www.medscape.com/viewarticle/843768
A very early and more intensive rehabilitation program was associated with a reduced likelihood of achieving a favorable outcome at 3 months vs usual care in the first large-scale randomized trial of rehabilitation therapy in patients with acute stroke.
The AVERT study results were presented by Professor Julie Bernhardt, PhD, Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia, at the inaugural European Stroke Organisation (ESO) Conference 2015. They were also simultaneously published online in The Lancet.
"Our data show that an early, lower-dose out-of-bed activity regimen is preferable to very early, frequent, higher-dose intervention," Professor Bernhardt concluded.
"This was an unexpected and intriguing result," she added. "But it tells us something very important. Earlier intensive rehabilitation was significantly worse than usual care. We have to listen to that."
She said that preclinical work and previous smaller studies have suggested that more intensive earlier rehabilitation would be beneficial. "But our results suggest we need to do more work to look at what is the right time for the brain to be challenged with this 'out of bed' intervention."
To Medscape Medical News she commented that the study had only just finished and it was too premature to issue strong recommendations.
"It is very early days," she said. "We will be coming up with clear recommendations for clinical practice, but for now we can say that earlier high-dose rehabilitation is not better than usual care, which in this study was still early but not quite as early or intensive as the more aggressive arm."
"However, the challenge is not as simple as just recommending usual care, because usual care is complex and this study was also delivered early and varied from center to center, and we had 56 centers in 5 countries. We have to unpack this so we can give clinicians guidance about their practice and this will be the next step."
She added: "We do know from previous studies that patients in stroke units who receive earlier rehabilitation than patients on general medical wards have better outcomes. So our message is not that patients should stay in bed for days."