Rajbeer Singh Sangha, MD
Liu N, Cadilhac DA, Andrew NE, Li Z, Li J, et al. Randomized Controlled Trial of Early Rehabilitation After Intracerebral Hemorrhage Stroke: Difference in Outcomes Within 6 Months of Stroke. Stroke. 2014
Current evidence suggests that early physical rehabilitation (VER) of stroke survivors in the acute stage may result in better motor recovery, reduced mental, functional and neurological disability, and improved quality of life. The previous studies that have been conducted regarding this topic have analyzed a small proportion of patients with ICH and there still remains a need for a larger phase three trial. According to the authors, the current general consensus that exists is that patients with ICH should be mobilized later than those with ischemic stroke, despite a lack of evidence to support this view. They aimed to compare Very Early Rehabilitation (VER) with standard care in patients with ICH and hypothesized that VER within 48 hours of ICH onset would result in reduced mortality, morbidity, and better quality of life outcomes compared to standard care at 3- and 6- months following stroke.
The study was a prospective, multi-centre, randomized controlled study, with 2 parallel groups followed for 6-months with blinded assessment of outcomes. Both groups received standard care, but participants in the VER group commenced rehabilitation as soon as practical after randomization but within 48 hours of ICH onset. In contrast, the standard care group commenced rehabilitation after 7 days. Out of 326 patients that were eligible, 243 patients were randomized (mean age 59 years; 56% male). At 6-months, patients receiving standard care were more likely to have died (aHR: 4.44, 95%CI: 1.24, 15.87). Further analysis of the morbidity outcomes showed a 6-point difference in the Physical Component Summary score of the SF-36 (95%CI 4.2, 8.7); a 7-point difference for the Mental Component Summary score (95%CI: 4.5, 9.5); a 13-point difference in Modified Barthel Index scores (95%CI: 6.8, 18.3), and a 6-point difference in SAS scores (95%CI: 4.4, 8.3) was reported in favor of the intervention groups.
The findings in this study point strongly towards ICH patients who were randomized to VER more likely to be alive at 6-months than those who received standard care alone. Patients who received VER also had a shorter length of hospital stay and reported significantly greater quality of life, independence with activities of daily living, and improved mental health outcomes at 6-months following stroke compared to those randomized to standard care. These results are in conjunction with previous smaller trials that have been conducted including the VERITAS trial in the UK and the AVERT phase II trial. While the authors could not account for the exact pathophysiological mechanism that lead to the improved outcomes, it should mean a significant change in the dogma towards rehabilitation in centers that wait for a period of 7 days or greater prior to starting. Further trials should focus on the specific techniques that would improve outcomes in a more efficient manner as well as more sensitive scales of measuring outcomes including the Neuro QOL which is a validated self-reported neurological assessment of quality of life.
But is this because objectively there was less of a dead epicenter and a smaller damaged penumbra? First you have to have an objective damage diagnosis or any of these trials are not repeatable or comparable.