Mobilization for Persons With Acute Stroke: A Survey of Current Physical Therapy Clinical Practice
Authors: Anderson Heather Dillon , Biely Scott 
Published: December 2019

Purpose:
To examine reported practice patterns of physical therapists (PTs) related to mobilization of persons with acute stroke. The researchers hypothesized that (1) facilities certified as primary stroke centers by The Joint Commission (TJC) will mobilize persons with acute stroke 24 hours or less after symptom onset; (2) persons with fewer impairments following acute stroke and those with ischemic stroke, who did not receive tissue plasminogen activator (tPA), are mobilized sooner; (3) PTs are the first to mobilize among interdisciplinary team members; and (4) PTs with more experience will mobilize sooner than novice PTs.

Methods

Survey Development: All members of the research team independently searched and reviewed the current literature describing the timing of initial mobilization after stroke. A pilot survey was developed from themes in the literature emphasizing areas hypothesized. Once the feedback from the pilot survey was reviewed, the survey was finalized and converted to an online survey using SurveyMonkey. Survey Implementation and Analysis: The target audience for the survey was PTs who treat persons with acute stroke. “Acute stroke,” for this survey, was defined as a stroke less than 1 week from onset of stroke symptoms. Potential respondents were contacted via e-mail through the APTA acute care and neurologic listservs. The survey contained 26 questions related to participant demographics, the timing and frequency of mobilization for persons with acute stroke based on defined impairment levels, perceptions about influences on mobilization, and knowledge of current related evidence. Descriptive result statistics were generated by SurveyMonkey. One-way analysis of variance was used to compare responses by practice setting, degree, APTA membership, and specialist certification. Spearman's rank correlation was used to correlate results based on participant characteristics.

Results:
A total of 161 PTs participated with a mean of 15 years' clinical practice. Most (67%) of the respondents report mobilizing persons with minimal impairment and uncomplicated ischemic stroke, not treated with tPA, in 24 hours or less. PTs were identified as the first to mobilize persons after stroke with severe (95%) and moderate impairments (91%). Recipients of tPA, persons with severe impairment, and those who received neurosurgical intervention were initially mobilized between 25 and 48 hours majority of the time. PTs working for a TJC stroke-certified institution did not mobilize sooner. The number of years of PT experience had a weak negative correlation to the timing of mobilization. Most respondents (58%) reported that mobilization more than 2 times per day is optimal. The barriers to more frequent mobilization included increased caseload, lack of resources, and lack of interdisciplinary patient care coordination.

Conclusions:
The frequency of mobilization reported in this survey is less than proposed by the results of the most recent “A Very Early Rehabilitation Trial” (AVERT) after stroke, phase 3 trial. This study found a positive correlation between increased session frequency and recovery of walking at 3 months, survival, and a modified Rankin Scale (mRS) score of 2 or less. Respondents believe additional mobilization would be beneficial, but report barriers to implementation that include increased PT caseloads and lack of resources. Additional research is required to determine the influence of mobilization timing and frequency on patient outcomes such as the degree of disability after stroke.