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Stroke Early Mobilisation Following Stroke Eitan Auriel 1 and Natan M Bornstein 2 1. Physician; 2. Professor, Stroke Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel Abstract Rehabilitation has been shown to influence brain recovery and to reduce the number of patients who are left handicapped following stroke; however, a question emerges in terms of the optimal time-point to initiate mobilisation. Very early mobilisation involves starting mobilisation including sitting up, getting out of bed, standing and walking, soon after stroke and continuing at frequent intervals. Several studies show evidence that very early rehabilitation has the potential to prevent complications and improve long-term outcomes compared with standard care. This article will discuss the benefits as well as safety concerns of this distinctive type of post-stroke care. Keywords Early mobilisation, rehabilitation, stroke Disclosure: Eitan Auriel has no conflicts of interest to declare. Natan M Bornstein serves on the Advisory Board and Speakers Bureau for EVER Neuro Pharma and has received honoraria for these tasks. Received: 26 October 2013 Accepted: 19 November 2013 Citation: European Neurological Review, 2013;8(2):141–3 Correspondence: Natan M Bornstein, Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel. E: Support: The publication of this article was supported by EVER Neuro Pharma. The views and opinions expressed are those of the authors and not necessarily those of EVER Neuro Pharma. Stroke is a sudden loss of cerebral blood flow caused either by occlusion (85  % of cases) or rupture of the cerebral artery manifesting with focal neurological deficits. 1 One-third of stroke patients are younger than and two-thirds are older than 65 years of age. 2 Stroke can have both immediate and ongoing physical consequences. Disability and mortality represent the most relevant clinical outcomes. The degree of disability varies from devastating outcome with total dependence on family/carer to minimal and manageable disability. 3 Within 12 months of stroke, one-third of stroke patients will die and another third are left with restriction in performing simple activities of daily living (ADL). Considering the high prevalence of the disease, the burden of post-stroke disability is of primary public health importance, translating to a substantial cost worldwide. In the US in 2008, for example, the direct and indirect costs of stroke are estimated to be more than $65 billion. 4 Much of this cost probably relates to the physical disability. Any treatment that improves functional outcome can significantly reduce disability and costs, setting regaining of functional independence, defined as improvement in mobility and activities of ADL, as an important goal. 4 The potential for recovery varies substantially across stroke patients. Factors associated with poor functional recovery include stroke severity, age and, to a lesser extent, diabetes. 5 Today, rehabilitation is recognised as a cornerstone of multidisciplinary stroke care and can reduce the number of patients who are left handicapped. Forty per cent of stroke patients require active rehabilitation services. 3 In recent years, rehabilitation has been shown to influence both brain recovery and reorganisation, especially in relation to motor impairment. Comprehensive rehabilitation programmes appear to improve functional recovery over standard care in terms of speed and extent of recovery. 6 It is noteworthy that neurological recovery is not linear and most of it occurs within the first 3–6 months, although some patients show recovery over prolonged timelines. © TO U CH MED ICA L MEDIA 201 3 Rehabilitation intensity depends on the status of the patient and degree of disability. If the patient is unconscious, rehabilitation is passive to prevent contractions, pressure ulcers and to prevent distress when movement is regained. 3 However, there is still debate regarding the optimal intensity of physical therapy following stroke, with conflicting results across the different studies ranging from no benefit to significant functional improvement. 6 This discrepancy may reflect differences in methodology, patient selection and outcome scales. The Rationale Behind Very Early Mobilisation Very early mobilisation (VEM) is a distinctive characteristic of care that involves starting mobilisation, including sitting up, getting out of bed, standing and walking, early after stroke and continuing at frequent intervals. However, the exact meaning of VEM is not well established and varies between 1 day to 3 months following symptoms onset. 7 Previous studies have shown that induction of neurotrophic factors is associated with neural repair within the first 2  weeks after stroke and, thus, may modulate greater plasticity that may restore function in the peri- infarct tissue and supplementary motor areas. 8 This experience dependent cortical plasticity has been well documented in normal and injured brains. 7 It may also enable the brain to better respond to rehabilitation, suggesting that efficacy of therapy may vary considerably with the timeline of initiation. The interaction between plasticity and recovery is, however, complicated and individualistic; therefore, it is of importance to apply the appropriate rehabilitation strategy at the appropriate time. Efforts are being made to develop more efficient rehabilitate strategies that utilise current knowledge of cortical plasticity. In addition to enhancing plasticity, VEM 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 141