Wednesday, October 1, 2008

Very Early Mobilization Cuts Rates of Poststroke Depression by 50%

By: Caroline Cassels

Medscape Medical News 2008.

September 30, 2008 — Very early mobilization of stroke patients within 24 hours of symptom onset significantly reduces rates of depression in this population.

These latest phase 2 findings from A Very Early Rehabilitation Trial (AVERT), show getting stroke patients up and out of bed within 24 hours of symptom onset cuts rates of severe depression by 50% 7 days after the stroke.

"We were surprised at the strength of these results and the impact very early and frequent mobilization had on severe depressive symptoms — 42% for controls vs 21% for those in the intervention group is quite a marked difference," study investigator Toby Cumming, PhD, from the National Stroke Research Institute, in Victoria, Australia, told Medscape Psychiatry.

"We need to stress that these are preliminary findings from quite a small study. Nevertheless, the results are exciting and quite unexpected. Based on these results and our earlier findings, I think we'd encourage people to consider mobilizing stroke patients earlier, because it may have beneficial effects, and reducing depression may be 1 of them," he said.

The study is published in the September issue of the Journal of Rehabilitation Medicine.

Poststroke Depression Common

Previous research shows approximately one-third of all stroke patients experience depression. Further, said Dr. Cumming, poststroke depression has also been associated with poor outcomes, including increased mortality, poorer rate and extent of recovery, poorer quality of life, and reduced participation in rehabilitation programs.

In addition, studies examining detection and treatment of poststroke depression show that it is commonly underdiagnosed and undertreated.

"If we can find a way to reduce poststroke depression, we may be able to positively affect many of these other, very important stroke outcomes, which is a really exciting possibility," he said.

The current results build on earlier feasibility and safety results from AVERT, a randomized controlled trial designed to compare outcomes in stroke patients who undergo very early mobilization (VEM) with those who receive standard care (SC).

The study included 71 patients with confirmed stroke who were admitted to 1 of 2 large centers within 24 hours of symptom onset and randomized to receive SC or VEM. Both groups were comparable with respect to demographics, impairment, disability, and all other baseline measures.

Patients in the VEM group began mobilization as soon as it was practical, with the aim of first mobilization within 24 hours of symptom onset. A nurse and physiotherapist team delivered VEM for the first 14 days after admission or until the patient was discharged, whichever came first.

No Sustained Effect

The study's primary outcome was patient well-being measured using the Irritability, Depression, and Anxiety (IDA) scale. Subjects were assessed at day 7 and 14 and again at 3, 6, and 12 months after stroke.

At 7 days, investigators found depressive symptoms were significantly more common in the SC group than in VEM patients. While there was a trend toward anxiety reduction in the VEM group, this was not statistically significant.

According to the investigators, it is well know that physical activity reduces depression in healthy individuals, but it is not known whether this effect endures once exercise ceases.

The study showed that VEM reduced depression in the immediate poststroke phase. However, at 1 year there was no difference between the 2 groups, a finding that may suggest the need for ongoing physical activity intervention to keep depressive symptoms at bay in this patient population.

Further research, said Dr. Cumming, is needed to shed light on whether the potential mechanism is psychological, physiological, or some combination of the 2. He said he is also interested examining the possibility that early mobilization may help improve cognition in stroke patients.

The study was supported by the National Heart Foundation of Australia, Affinity Health, Austin Health Medical Research Fund, and the National Health and Medical Research Council.

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