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August 13, 2019; 93 (7) Null Hypothesis

Early mobilization and quality of life after stroke

Findings from AVERT

View ORCID ProfileToby B. Cumming, Leonid Churilov, Janice Collier, Geoffrey Donnan, Fiona Ellery, Helen Dewey, Peter Langhorne, View ORCID ProfileRichard I. Lindley, Marj Moodie, Amanda G. Thrift, Julie Bernhardt, on behalf of the AVERT Trial Collaboration group
First published July 26, 2019, DOI: https://doi.org/10.1212/WNL.0000000000007937
Toby B. Cumming
From Florey Institute of Neuroscience and Mental Health (T.B.C., L.C., J.C., G.D., F.E., J.B.), University of Melbourne; Eastern Health Clinical School (H.D.) and Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; Westmead Hospital Clinical School (R.I.L.), University of Sydney and George Institute for Global Health, Sydney; Faculty of Health (M.M.), Deakin University, Melbourne, Australia.
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  • ORCID record for Toby B. Cumming
Leonid Churilov
From Florey Institute of Neuroscience and Mental Health (T.B.C., L.C., J.C., G.D., F.E., J.B.), University of Melbourne; Eastern Health Clinical School (H.D.) and Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; Westmead Hospital Clinical School (R.I.L.), University of Sydney and George Institute for Global Health, Sydney; Faculty of Health (M.M.), Deakin University, Melbourne, Australia.
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Janice Collier
From Florey Institute of Neuroscience and Mental Health (T.B.C., L.C., J.C., G.D., F.E., J.B.), University of Melbourne; Eastern Health Clinical School (H.D.) and Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; Westmead Hospital Clinical School (R.I.L.), University of Sydney and George Institute for Global Health, Sydney; Faculty of Health (M.M.), Deakin University, Melbourne, Australia.
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Geoffrey Donnan
From Florey Institute of Neuroscience and Mental Health (T.B.C., L.C., J.C., G.D., F.E., J.B.), University of Melbourne; Eastern Health Clinical School (H.D.) and Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; Westmead Hospital Clinical School (R.I.L.), University of Sydney and George Institute for Global Health, Sydney; Faculty of Health (M.M.), Deakin University, Melbourne, Australia.
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Fiona Ellery
From Florey Institute of Neuroscience and Mental Health (T.B.C., L.C., J.C., G.D., F.E., J.B.), University of Melbourne; Eastern Health Clinical School (H.D.) and Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; Westmead Hospital Clinical School (R.I.L.), University of Sydney and George Institute for Global Health, Sydney; Faculty of Health (M.M.), Deakin University, Melbourne, Australia.
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Helen Dewey
From Florey Institute of Neuroscience and Mental Health (T.B.C., L.C., J.C., G.D., F.E., J.B.), University of Melbourne; Eastern Health Clinical School (H.D.) and Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; Westmead Hospital Clinical School (R.I.L.), University of Sydney and George Institute for Global Health, Sydney; Faculty of Health (M.M.), Deakin University, Melbourne, Australia.
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Peter Langhorne
From Florey Institute of Neuroscience and Mental Health (T.B.C., L.C., J.C., G.D., F.E., J.B.), University of Melbourne; Eastern Health Clinical School (H.D.) and Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; Westmead Hospital Clinical School (R.I.L.), University of Sydney and George Institute for Global Health, Sydney; Faculty of Health (M.M.), Deakin University, Melbourne, Australia.
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Richard I. Lindley
From Florey Institute of Neuroscience and Mental Health (T.B.C., L.C., J.C., G.D., F.E., J.B.), University of Melbourne; Eastern Health Clinical School (H.D.) and Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; Westmead Hospital Clinical School (R.I.L.), University of Sydney and George Institute for Global Health, Sydney; Faculty of Health (M.M.), Deakin University, Melbourne, Australia.
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Marj Moodie
From Florey Institute of Neuroscience and Mental Health (T.B.C., L.C., J.C., G.D., F.E., J.B.), University of Melbourne; Eastern Health Clinical School (H.D.) and Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; Westmead Hospital Clinical School (R.I.L.), University of Sydney and George Institute for Global Health, Sydney; Faculty of Health (M.M.), Deakin University, Melbourne, Australia.
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Amanda G. Thrift
From Florey Institute of Neuroscience and Mental Health (T.B.C., L.C., J.C., G.D., F.E., J.B.), University of Melbourne; Eastern Health Clinical School (H.D.) and Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; Westmead Hospital Clinical School (R.I.L.), University of Sydney and George Institute for Global Health, Sydney; Faculty of Health (M.M.), Deakin University, Melbourne, Australia.
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Julie Bernhardt
From Florey Institute of Neuroscience and Mental Health (T.B.C., L.C., J.C., G.D., F.E., J.B.), University of Melbourne; Eastern Health Clinical School (H.D.) and Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; Westmead Hospital Clinical School (R.I.L.), University of Sydney and George Institute for Global Health, Sydney; Faculty of Health (M.M.), Deakin University, Melbourne, Australia.
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From Florey Institute of Neuroscience and Mental Health (T.B.C., L.C., J.C., G.D., F.E., J.B.), University of Melbourne; Eastern Health Clinical School (H.D.) and Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; Westmead Hospital Clinical School (R.I.L.), University of Sydney and George Institute for Global Health, Sydney; Faculty of Health (M.M.), Deakin University, Melbourne, Australia.
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Early mobilization and quality of life after stroke
Findings from AVERT
Toby B. Cumming, Leonid Churilov, Janice Collier, Geoffrey Donnan, Fiona Ellery, Helen Dewey, Peter Langhorne, Richard I. Lindley, Marj Moodie, Amanda G. Thrift, Julie Bernhardt, on behalf of the AVERT Trial Collaboration group
Neurology Aug 2019, 93 (7) e717-e728; DOI: 10.1212/WNL.0000000000007937

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Abstract

Objective To determine whether early and more frequent mobilization after stroke affects health-related quality of life.

Methods A Very Early Rehabilitation Trial (AVERT) was an international, multicenter (56 sites), phase 3 randomized controlled trial, spanning 2006–2015. People were included if they were aged ≥18 years, presented within 24 hours of a first or recurrent stroke (ischemic or hemorrhagic), and satisfied preordained physiologic criteria. Participants were randomized to usual care alone or very early and more frequent mobilization in addition to usual care. Quality of life at 12 months was a prespecified secondary outcome, evaluated using the Assessment of Quality of Life 4D (AQoL-4D). This utility-weighted scale has scores ranging from −0.04 (worse than death) to 1 (perfect health). Participants who died were assigned an AQoL-4D score of 0.

Results No significant difference in quality of life at 12 months between intervention (median 0.47, interquartile range [IQR] 0.07–0.81) and usual care (median 0.49, IQR 0.08–0.81) groups was identified (p = 0.86), nor were there any group differences across the 4 AQoL-4D domains. The same lack of group difference in quality of life was observed at 3 months. When cohort data were analyzed (both groups together), quality of life was strongly associated with acute length of stay, independence in activities of daily living, cognitive function, depressive symptoms, and anxiety symptoms (all p < 0.001). Quality of life in AVERT participants was substantially lower than population norms, and the gap increased with age.

Conclusions Earlier and more frequent mobilization after stroke did not influence quality of life.

Clinical trial registration anzctr.org.au; ACTRN12606000185561

Classification of evidence This study provides Class II evidence that for people with stroke, earlier and more frequent mobilization did not influence quality of life over the subsequent year.

Glossary

AQoL-4D=
Assessment of Quality of Life 4D;
AVERT=
A Very Early Rehabilitation Trial;
CI=
confidence interval;
IDA=
Irritability, Depression and Anxiety;
IQR=
interquartile range;
MoCA=
Montreal Cognitive Assessment;
mRS=
modified Rankin Scale;
NIHSS=
NIH Stroke Scale;
QOL=
quality of life

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Class of Evidence: NPub.org/coe

  • Received August 28, 2018.
  • Accepted in final form March 21, 2019.
  • © 2019 American Academy of Neurology
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