Very Early Mobilization After Stroke Fast-Tracks Return

to Walking
Further Results From the Phase II AVERT Randomized Controlled Trial
Toby B. Cumming, PhD; Amanda G. Thrift, PhD; Janice M. Collier, PhD; Leonid Churilov, PhD;
Helen M. Dewey, PhD; Geoffrey A. Donnan, MD; Julie Bernhardt, PhD
Background and PurposeRegaining functional independence is an important goal for people who have experienced
stroke. We hypothesized that introducing earlier and more intensive out-of-bed activity after stroke would reduce time
to unassisted walking and improve independence in activities of daily living.
MethodsA Very Early Rehabilitation Trial (AVERT) was a phase II randomized controlled trial. Patients with confirmed
stroke (infarct or hemorrhage) admitted 24 hours after stroke and who met physiological safety criteria were eligible.
Patients randomized to the very early and intensive mobilization group were mobilized within 24 hours of stroke and
at regular intervals thereafter. Control patients received standard stroke unit care. The primary outcome for this analysis
was the number of days required to return to walking 50 m unassisted. Secondary outcomes were the Barthel Index and
Rivermead Motor Assessment at 3 and 12 months after stroke.
ResultsSeventy-one stroke patients with a mean age of 74.7 years were recruited from 2 hospitals. Adjusted Cox
regression indicated that very early and intensive mobilization group patients returned to walking significantly faster
than did standard stroke unit care controls (P0.032; median 3.5 vs 7.0 days). Multivariable regression revealed that
exposure to very early and intensive mobilization was independently associated with good functional outcome on the Barthel
Index at 3 months (P0.008) and on the Rivermead Motor Assessment at 3 (P0.050) and 12 (P0.024) months.
ConclusionsEarlier and more intensive mobilization after stroke may fast-track return to unassisted walking and improve
functional recovery.
Clinical Trial RegistrationThis trial was not registered because enrollment began before July 2005.
(Stroke. 2011;42:153-158.)
Key Words: acute care cerebrovascular disease functional recovery randomized controlled trials
rehabilitation

unable to walk without assistance in the first week after

stroke.6 Among those initially unable to walk, 95% of
patients recovered within the first 3 months, with leg paresis
strongly associated with the rate of recovery. In addition to
stroke severity,7,8 increasing age8,9 and diabetes8,10 are factors
that have been associated with a lower rate and extent of
functional recovery after stroke.
Both the speed and extent of recovery are important to
survivors of stroke, yet research examining the efficacy of
interventions on recovery milestones is limited. A meta-analysis of studies that included augmented exercise intensity
revealed a positive effect on ADLs in the first 6 months after
stroke.3 Treatment in a dedicated stroke unit has been
associated with more rapid and greater recovery of independence in ADLs when compared with patients treated on a

s a consequence of focal brain ischemia or hemorrhage,

stroke can have both immediate and ongoing physical
effects. Within 12 months of stroke, one third of stroke
patients will die and another third are left with disability,
restricted in performing simple activities of daily living
(ADLs) and requiring some kind of assistance.1 Of all
recovery goals, improved walking function is the one most
often expressed by patients with stroke.2
The rate of physical recovery is not linear; the most rapid
improvement occurs within the first 6 months after stroke.3,4
In a study of 976 acute stroke patients, Wade and Hewer5
reported some recovery between 3 weeks and 6 months in
almost all patients, and by 6 months, approximately half of
the survivors had regained functional independence. In another large study, approximately two thirds of patients were

Received June 24, 2010; accepted August 11, 2010.

From the Florey Neuroscience Institutes (T.B.C., A.G.T., J.M.C., L.C., H.M.D., G.A.D., J.B.), Austin Campus; Department of Medicine (H.M.D.,
G.A.D., J.B.), University of Melbourne; Department of Neurology (H.M.D., G.A.D.), Austin Health; Baker IDI Heart and Diabetes Institute, and
Department Epidemiology and Preventive Medicine (A.G.T.), Monash University; and School of Physiotherapy (J.B.), La Trobe University, Melbourne,
Australia.
Correspondence to Julie Bernhardt, Level 2, Neurosciences Building, 300 Waterdale Road, Heidelberg Heights, Victoria, Australia, 3081. E-mail
[email protected]
2010 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org

DOI: 10.1161/STROKEAHA.110.594598

153

154

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January 2011

general medical ward.11 Walking recovery was not specifically measured in this study, but a post hoc analysis indicated
that a shorter time to start of mobilization after stroke onset
was the most important factor associated with discharge to
home.12 Given the general lack of physical activity in the first
weeks after stroke,13 we believed that there was an opportunity to introduce earlier and more frequent mobilization. The
safety and feasibility of this intervention were the primary
outcomes tested as part of a phase II clinical trial comparing
a very early and intense mobilization protocol (VEM) with
standard stroke unit care (SC).14 In the current article, we
report the outcomes associated with recovery of walking and
independence in ADLs. We hypothesized that patients in the
VEM group would walk unassisted sooner than SC controls.
We also hypothesized that VEM patients would achieve
better functional independence (as measured by the Barthel
Index and Rivermead Motor Assessment) than SC controls at
3 and 12 months after stroke.

Methods
Design
A Very Early Rehabilitation Trial (AVERT) phase II was a prospective randomized controlled trial with concealed allocation, blinded
assessment of outcomes, and intention-to-treat analysis. The setting
was the acute stroke units of 2 large hospitals in Melbourne,
Australia. Ethics approval was obtained. The methods have been
reported in detail elsewhere14 and are summarized in the
subsequent paragraphs.

Population
Patients were included if they (1) were 18 years; (2) satisfied
physiological limits (systolic blood pressure 120 to 220 mm Hg,
heart rate 40 to 100 bpm, oxygen saturation 92%, and temperature
38.5o); and (3) could be randomized within 24 hours of symptom
onset of a first or recurrent stroke. Patients were excluded if they had
a premorbid modified Rankin Scale (mRS)15 score 3 (indicating
disability), deterioration within the first hour of admission to the
stroke unit or direct admission to intensive care, concurrent progressive neurological disorder, acute coronary syndrome, severe heart
failure, lower-limb fracture that prevented mobilization, or required
palliative care.

Procedure
When discussing informed consent, patients were told that they
would be given 1 of 2 different types of rehabilitation. Computergenerated, blocked randomization procedures and concealment with
opaque envelopes were used to allocate patients to either the VEM or
SC group. Randomization was stratified by hospital site and stroke
severity on the National Institutes of Health Stroke Scale (NIHSS)16
(mild0 to 7, moderate8 to 16, and severe 16) to reduce the
likelihood of severity imbalance between groups.

Intervention
Both VEM and SC groups received standard care from ward
therapists and nursing staff in the stroke units. Patients randomized
to the VEM group began mobilizing as soon as practical after
randomization, with the goal of first mobilization within 24 hours of
stroke onset. The VEM group also received additional interventions,
with the aim of assisting patients to be upright and out of bed at least
twice per day, thereby doubling the standard care mobilization
dose previously identified. VEM was delivered by a trained nurse
and physiotherapist team for the first 14 days after stroke or until
discharge from the acute stroke unit (whichever was sooner). The
type and dose of therapy for both groups were recorded on personal
digital assistants. Occupational health and safety procedures for

manual handling of patients were maintained. Blood pressure, heart

rate, oxygen saturation, and temperature were monitored before the
first 3 mobilizations of VEM patients. Contamination of standard
care was monitored throughout the study.

Baseline Assessment
Baseline assessment included age, sex, stroke type according to the
Oxfordshire stroke classification,17 stroke severity on the NIHSS,
diabetes status as well as other stroke risk factors, prestroke living
arrangements, and prestroke functional level on the mRS. The
mobility scale for acute stroke18 was used to establish baseline
restrictions in a patients ability to move in bed, sit up, and walk 10
m, and information from this scale was used to guide the VEM
intervention level.

Outcome Measures
Assessments by the blinded assessor took place at 7 and 14 days and
3, 6, and 12 months after stroke. For this data analysis, the main
outcome of interest was time to walking 50 m. This was defined as
the number of days from stroke onset until the patient could first
walk 50 m without human assistance, a distance used in the
Functional Independence Measure19 walking item and commonly
marked out within hospital departments. To remove the subjectivity
associated with both the need for supervision (Functional Independence Measure score 5) and walking aid (Functional Independence
Measure score 6), we defined walking as walking unassisted by
human help (gait aid allowed) for a continuous distance of 50
meters. Physiotherapists were responsible for completion of the
50-m walk.
The other outcome measures were the Barthel Index5 and Rivermead Motor Assessment,20 both assessed at 3 and 12 months after
stroke. The Barthel Index, a valid and reliable measure of ADLs in
stroke research,21,22 was used to assess independence in 10 everyday
activities. The total score sums to 20, and higher scores reflect better
performance. As per common practice with the Barthel Index,
patients were classified as either independent (score20) or dependent (score0 to 19) in ADLs. The Rivermead Motor Assessment
gross function scale of 13 items was used to examine motor activity
and has established reliability in stroke.23,24 It includes easy and
difficult items, with the first item testing unsupported sitting, and
other items testing ability to transfer, walk indoors, walk outdoors,
run, and hop on the spot. The best performance of 3 trials on each
item was scored, with a score of 0 indicating that the patient was
unable to perform any of the activities independently and a score of
13 indicating independence with all activities. Patients were classified as
either impaired (score0 to 9) or not impaired (score10 to 13) in
motor activity, a cutoff chosen to align with the clinically meaningful
ability to walk outside the home (community ambulation).

Statistical Analysis
A sample of 70 patients was deemed sufficient to allow examination
of the primary safety outcome of the study (death) at 3 months after
stroke.14 Although the study was not powered to detect differences in
physical outcomes reported in this article, an important part of
feasibility testing includes evaluation of performance and utility of
the outcome measures used.
Because one third of stroke patients die in the first 12 months,1
analyses must deal with missing data due to deaths. Furthermore,
when inclusion criteria are broad, as in this trial, stroke symptoms
can vary markedly, with the result that some patients will fail to
achieve any score on a given test, particularly those related to higher
levels of activity. Excluding patients who died or who failed to
achieve a score on a test would bias results, and imputing data values
for these subjects requires guesswork. In this study, all patients who
died were assigned a score of 0 on the Barthel and Rivermead scales
for all subsequent time points. A score of 0 was deemed likely to
reflect their status had they still been alive, given that people who die
in the first year after stroke are more likely to have had a severe
stroke (and would be expected to have a very low score on these
measures). Patients alive at the time of assessment with missing data

Cumming et al

Early Mobilization After Stroke Improves Walking

Table 1.

Randomised
N=71

V
Very
early
l mobilisation
bili ti
N=38

Baseline

Standard
S
d d care
N=33

Baseline Characteristics of Recruited Patients

SC
n33
No. (%)*

VEM
n38
No. (%)*

Total
N71
No. (%)*

74.9 (9.8)

74.6 (14.6)

74.7 (12.5)

17 (53)

16 (42)

33 (46)

14 (42)

22 (58)

36 (51)

Mild (17)

15 (46)

15 (39)

30 (42)

Moderate (816)

11 (33)

13 (34)

24 (34)

7 (21)

10 (26)

17 (24)

Patient details
Age, mean (SD), y
3 deaths

8 deaths
N=30

3 months

Female
Stroke details

N=30

Left-sided lesion

3 deaths
2 withdrawals

3 deaths

N=25

12 months

155

N=27

Figure 1. Participant flowchart.

NIHSS score

Severe (16)
Oxfordshire Stroke Classification

were not included in analyses. Multivariable analyses were used to

account for demographic and stroke-related factors known to influence walking and functional independence (age, stroke severity, and
diabetes) and other factors that may also impact these outcomes (sex
and premorbid disability).

Days to Walking
The number of days between stroke onset and a 50-m unassisted
walk was recorded. A Cox regression was performed with adjustment for important prognostic variables (age, sex, NIHSS, premorbid
mRS and diabetes).

Barthel Index
Mann-Whitney U tests were used to assess between-group differences in Barthel score. Barthel data were then used to classify
patients as either independent or dependent in ADLs, and Fishers
exact tests were used to detect group differences. Multivariable
logistic-regression analyses, with the Barthel Index as the binary
outcome measure, were then performed to determine the effect of
group (VEM or SC), age, sex, NIHSS, premorbid mRS and diabetes
on independence in ADLs.

Rivermead Motor Assessment

Between-group differences in Rivermead scores were analyzed by
Mann-Whitney U tests. Rivermead data were then used to classify
patients as either impaired or not impaired in motor activity, and
Fishers exact tests were used to detect group differences. Multivariable logistic-regression analyses were then performed on the binary
Rivermead data in the same way as described for the Barthel Index.

TACI

6 (18)

10 (26)

16 (23)

PACI

10 (30)

13 (34)

23 (32)

POCI

5 (15)

7 (18)

12 (17)

LACI

6 (18)

5 (13)

11 (15)

ICH

6 (18)

3 (8)

9 (13)

7 (21)

11 (29)

18 (25)

Hypertension

25 (76)

25 (66)

50 (70)

Ischemic heart disease

13 (39)

7 (18)

20 (28)

9 (27)

5 (13)

14 (20)

Prior history of stroke

Stroke risk factors

Angina
Hypercholesterolemia
Diabetes

11 (33)

8 (21)

19 (27)

4 (12)

11 (29)

15 (21)

15 (45)

15 (47)

30 (46)

Smoking
Never smoked
Smoker
Ex-smoker
Unknown

6 (18)

7 (22)

13 (20)

12 (36)

10 (31)

22 (34)

0 (0)

6 (16)

6 (8)

Factors limiting mobilization

Respiratory

5 (15)

4 (11)

9 (13)

Lower limb

7 (21)

11 (29)

18 (25)

Premorbid history
Premorbid mRS
0

20 (61)

18 (47)

38 (54)

Results

8 (24)

6 (16)

14 (20)

Seventy-one patients were recruited from 2004 to 2006: 60

from the Austin Hospital and 11 from St. Vincents Hospital
(Figure 1). Baseline characteristics between groups were
similar (Table 1). Notably, 58% of the sample had moderate
or severe stroke. Median time to mobilization was shorter in
VEM (18 hours) than in SC (31 hours), and the median total
dose of mobilization was greater for VEM (167 minutes) than
for SC (69 minutes).14 By 3 months, 11 patients (15%) had
died, and at 12 months, 17 patients (24%) had died. The
proportion of deaths between groups was not different and
was low compared with population-based studies.14 Three
surviving patients had missing data, but inspection of their
characteristics showed that any systematic bias was unlikely.
They were not all from one group (2 VEM, 1 SC), they had
a range of ages (58, 82, and 86 years), and they did not have
severe stroke (NIHSS of 1, 5 and 7).

2 (6)

8 (21)

10 (14)

3 (9)

6 (16)

9 (13)

7 (21)

4 (11)

11 (15)

25 (76)

30 (79)

55 (78)

1 (3)

4 (11)

5 (7)

Living arrangement on
admission
Home , alone
Home, with someone
Hostel

*No. (percent) unless otherwise indicated.

TACI indicates total anterior circulation infarct; PACI, partial anterior
circulation infarct; POCI, posterior circulation infarct; LACI, lacunar infarct; and
ICH, intracerebral hemorrhage.
Smokercurrent smoker or who quit within the last 2 years. Exsmokerquit 2 years ago.
Respiratory limiting factors included emphysema and chronic obstructive
airway disease.
Lower-limb limiting factors included lower-limb arthritis and lower-limb
joint replacement.

156

Stroke

January 2011

Table 2. Cox Regression for No. of Days to Walking 50 m

Unassisted (N71)
P

Table 3. Multivariable Binary Logistic Regressions, With

Independence in ADLs (Barthel Index20 vs Barthel
Index0 19) at 3 and 12 Months as the Outcome Variable

Hazard Ratio

Lower CI

Upper CI

VEM

0.523

0.289

0.945

0.032

Age

0.967

0.944

0.990

0.005

Sex

0.679

0.374

1.233

0.204

VEM

11.24

1.88

NIHSS

0.864

0.815

0.916

0.001

Age

0.85

0.75

Premorbid mRS

0.867

0.645

1.165

0.344

Sex

1.33

Diabetes

2.147

1.020

4.520

0.044

NIHSS

Days to Walking
On admission, 86% of patients could not walk or required
hands-on assistance to walk short distances (mobility scale
for acute stroke gait score 1 to 4; VEM n34, SC n27).
Only 14% of patients were rated as able to walk with
supervision (VEM n4, SC n6). Median days taken to
return to walking 50 m was 3.5 (interquartile range
[IQR]1.5 to 14.0) in the VEM group and 7.0 (IQR2.0 to
20.0) in the SC group. At 2 weeks after stroke (the end of the
intervention period) among surviving patients, 67% (22 of
33) of the VEM group had returned to unassisted walking
compared with 50% (16 of 32) of the SC group. Results of the
Cox regression analysis, with adjustment for potentially
confounding variables, demonstrated a significant impact of
the intervention on time to walking (P0.032; Table 2). The
log-minus-log function indicated that the assumption of
proportionality was met. Patients in the VEM group returned
to independent walking sooner than did SC patients, as shown
in the adjusted survival curves (Figure 2). Earlier return to
walking after stroke was also independently associated with
less severe stroke (NIHSS), younger age, and absence of
diabetes (Table 2).

Barthel Index
Proxy respondents provided answers for 21% of 3-month
survivors and 17% of 12-month survivors (primarily due to
the patient having communication difficulties). The distribution of Barthel scores was bimodal, with most patients
clustered at either the low or high end of the scale. Scores on

Proportion walk
king 50m unassiisted

1.0

Very Early Mobilisation

Standard
St d d Care

0.8

0.6

0.4

0.2

0.0
0

20

40

60

80

100

120

140

Days post-stroke

Figure 2. Number of days to walking 50 m unassisted in VEM

and SC groups, adjusted for age, sex, stroke severity (NIHSS),
premorbid mRS, and diabetes (N71). Note: Of those patients
who returned to walk in the 12 months after stroke, 142 days
was the longest time taken.

3 Months (N68)*
OR

95% CI

12 Months (N69)
P

OR

95% CI

67.31

0.008

4.19

0.46

37.84

0.95

0.005

0.74

0.60

0.91

0.004

0.29

6.06

0.710

14.56

1.62

130.88

0.017

0.71

0.56

0.90

0.005

0.62

0.43

0.89

0.010

Premorbid
mRS

0.88

0.33

2.38

0.808

0.51

0.16

1.63

0.257

Diabetes

0.43

0.06

2.83

0.379

0.06

0.89

0.041

0.201

OR indicates odds ratio.

*Eleven patients who died were included by assigning a Barthel score of 0;
3 survivors had missing data.
Seventeen patients who died were included by assigning a Barthel score of
0; 2 survivors had missing data.

the Barthel Index at 3 months were higher for the VEM group
(median18.5, IQR2.0 to 20.0) than the SC group (median16.5, IQR9.0 to 20.0), but this difference was not
significant (P0.713). In VEM, 47% (17 of 36) of patients
had a good outcome on the Barthel Index at 3 months
compared with 28% (9/32) of SC patients (P0.136). Scores
on the Barthel Index at 12 months were not significantly
different between groups, with 39% of patients having a good
outcome in both VEM (median18.0, IQR0.0 to 20.0) and
SC (median18.0, IQR7.0 to 20.0) groups. In the multiple
regression analysis, having a good outcome on the Barthel
Index at 3 months was independently associated with exposure to VEM, less severe stroke on admission (NIHSS), and
younger age. Having a good Barthel outcome at 12 months
was independently associated with less severe stroke,
younger age, male sex, and absence of diabetes, but the effect
of exposure to VEM was no longer apparent (Table 3).
Results were similar when the analyses were restricted to
survivors only (data not shown).

Rivermead Motor Assessment

Scores on the Rivermead assessment at 3 months were similar
in VEM (median10.0, IQR0.5 to 11.0) and SC (median10.0, IQR3.0 to 11.0) groups (P0.883). In VEM,
62% (23 of 37) of patients had a good Rivermead outcome at
3 months compared with 56% (18 of 32) of SC patients
(P0.633). Scores on the Rivermead at 12 months were not
significantly different between groups, with 53% of VEM
patients having a good outcome (median10.0, IQR0.0 to
11.0) compared with 45% of SC patients (median9.0,
IQR1.0 to 11.0). In multiple regression, having a good
Rivermead outcome was independently associated with exposure to VEM, less severe stroke (NIHSS), and younger age,
at both 3 and 12 months (Table 4). Results were similar when
the analyses were restricted to survivors only, although age
was no longer associated with good outcome (data not
shown).

Discussion
The most important finding was that stroke patients who
received VEM in addition to standard stroke unit care were

Cumming et al

Early Mobilization After Stroke Improves Walking

Table 4. Multivariable Binary Logistic Regressions, With

Independence in Motor Function (Rivermead10 13 vs
Rivermead0 9) at 3 and 12 Months as the Outcome Variable
3 Months (N69)*
OR

95% CI

12 Months (N69)
P

OR

95% CI

VEM

8.21

1.00

67.64

0.050

9.62

1.34

68.83

0.024

Age

0.90

0.81

1.00

0.046

0.88

0.78

0.98

0.024

Sex

1.52

0.27

8.67

0.635

4.44

0.83

23.65

0.081

NIHSS

0.66

0.54

0.82

0.001

0.71

0.59

0.85

0.001

Premorbid
mRS

0.66

0.27

1.62

0.361

0.44

0.18

1.05

0.065

Diabetes

0.71

0.08

6.38

0.761

0.13

0.02

1.07

0.058

OR indicates odds ratio.

*Eleven patients who died were included by assigning a Rivermead score of
0; 2 survivors had missing data.
Seventeen patients who died were included by assigning a Rivermead
score of 0; 2 survivors had missing data.

able to walk unassisted sooner than patients who received

standard stroke unit care alone. One major clinical implication of this result is that walking sooner increases the
likelihood of milder stroke patients being discharged from
acute care directly to home rather than to a rehabilitation
facility. Our data support this possibility: despite the VEM
group having more patients with moderate to severe strokes
than the SC group, length of stay in the acute care hospital
was shorter for VEM than for SC patients (median 6 vs 7
days), and they were more likely to be discharged directly to
home (32% vs 24%). The study by Indredavik et al,12 in
which a shorter time to start of mobilization was the most
important factor associated with discharge to home, also
supports this idea. A potential explanation for the faster return
to walking is that motor performance was improved by earlier
and more frequent out-of-bed experiences. It is also possible
that the increased physical activity served to minimize the
muscle loss and deterioration in cardiorespiratory function
associated with bed rest25 and thus made walking 50 m
unassisted less demanding. A further possibility is that
self-efficacy was enhanced; that is, the early sessions of
mobilization constituted mastery experiences that gave the
patient increased confidence in his or her own ability to
walk.26,27
Our hypothesis that patients exposed to the intervention
would have better functional independence than controls at 3
months was supported by the findings from the multiple
regression analyses, whereby more VEM patients were independent in ADLs (Barthel Index) and motor function (Rivermead Motor Assessment) than SC patients. Taken together
with the walking findings, this indicates that providing earlier
and more intensive mobilization after stroke can accelerate
the recovery of meaningful physical outcomes. At 12 months,
VEM patients remained more independent in motor function
than controls, but there was no significant group difference
for independence in ADLs. Previous studies have demonstrated that in the longer term, stroke patients who have not
received augmented training eventually achieve the same
level of function as those who have.3 It should be noted that
our study was not powered to detect changes in functional

157

outcomes in response to the addition of an early mobilization

program. As Tables 3 and 4 show, the confidence intervals
around the effect of intervention group were wide, and
whether these promising findings are confirmed in the larger
phase III study (currently underway)28 remains to be seen.
Age and stroke severity strongly influenced recovery as
measured by the Barthel and Rivermead at both 3 and 12
months after stroke, with younger patients and those with less
severe stroke achieving greater functional independence. This
is consistent with previous findings.79 The negative influence of diabetes on functional independence found with
walking recovery and the Barthel Index at 12 months also has
precedent.8,10
As outcome measures in a research context, the Barthel
Index and Rivermead Motor Assessment are not perfect.
They are brief, ordinal scales that produce data that are not
normally distributed, with ceiling effects a particular issue for
the Barthel. It is possible that differences in independence in
ADLs between groups were present at 12 months in the
current study but that a ceiling effect in the Barthel data
precluded their detection. More than half of the surviving
patients were at ceiling on the Barthel scale (20/20) at 12
months after stroke. The weakness of the Barthel in discriminating between people at moderate versus high levels of
function has been well documented.29 Furthermore, neither
the Barthel nor the Rivermead measure incorporates death in
its scale (as the mRS does). In contrast to many published
rehabilitation studies, deaths were not excluded from our
analyses of physical outcomes. Rather, we assigned patients
who had died a score of 0 for both the Barthel and Rivermead
measures to prevent overestimation of recovery in this group.
In light of these considerations, it was necessary to dichotomize the Barthel and Rivermead data for analyses so that
statistical assumptions were not violated. The consequence of
the dichotomization approach is a reduction in sensitivity of
the measures. These assessments, however, are widely used
and readily understood in rehabilitation settings (both clinical
and research), and this explains their choice as outcome
measures here.
Any intervention that accelerates functional recovery is
important both to stroke survivors and clinicians. This study
provides novel evidence that earlier and more intensive
mobilization in the acute phase of stroke can accelerate
recovery of walking and functional independence. The findings from AVERT phase III will provide greater certainty
regarding the efficacy of VEM in the recovery of physical
independence after stroke.

Acknowledgments
We thank all of the stroke survivors and their caregivers who
participated in this study. We gratefully acknowledge the support of
the clinical staff at the Austin Hospital and St. Vincents Hospital
and all those involved at the National Stroke Research Institute.

Sources of Funding
This trial was supported by grants from the National Heart Foundation of Australia (grant number G 04M 1571), Affinity Health, and
an equipment grant from the Austin Health Medical Research Fund.
Dr Bernhardt was supported by a National Health and Medical
Research Council (Australia) fellowship (157305).

158

Stroke

January 2011

Disclosures
None.

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