There is no significant difference in the disability outcomes for patients who have suffered acute stroke, whether they received treatment lying flat on the back with the face upwards or in a sitting-up position with the head elevated to at least 30 degrees.
This is the conclusion of a major trial that involved over 11,000 acute stroke patients for a 90-day window.
In the case of stroke patients, it is believed that lying flat may improve recovery by increasing blood flow in the main arteries to the brain, but there has been no clinical evidence. There has also been uncertainty over the role of head positioning after acute stroke and the potential risks of cardiopulmonary dysfunction and pneumonia infection.
About 14 hours after the onset of stroke, the patients were made to lie in one of the two positions for 24 hours. The trial was carried out in 114 hospitals in nine countries, including India. The results of the study were published on June 22 in The New England Journal of Medicine (NEJM).
The trial involving about 5,300 patients assigned to lying-flat position and 5,800 patients in the sitting-up position found no significant differences between the two groups with respect to the amount of oxygen in the blood, blood pressure levels and other aspects of management. There was also no significant difference in mortality or in the rates of adverse side-effects including pneumonia between the two groups. The average age of the patients was 68 years and 85% had acute stroke caused by a clot present in the arteries.
“Our trial found that the body has the capacity to maintain blood flow to the brain immaterial of the position of the head soon after stroke,” says Dr. Jeyraj D. Pandian, Department of Neurology, Christian Medical College, Ludhiana and Honorary Professor at The George Institute for Global Health, and one of the authors of the paper. Any change in the blood flow to the brain as a result of head positioning initiated within 24 hours of stroke onset was found to be insufficient to reduce the neurologic severity associated with acute stroke.
Mild, moderate impact
All the patients enrolled in the trial had mostly mild to moderate neurologic severity caused by acute stroke and undergone initial treatment to dissolve or remove the clot before being enrolled for the trial.
Explaining why disability outcomes at the end of 90 days were considered, Dr. Pandian says: “Ninety days is the right period during the stroke-recovery phase when it becomes clear whether the patient will further improve or not. If someone does not improve in the first three months then he is less likely to improve in six months or one year.” The first three months is critical as the majority of rewiring of the nerve cells happens on or before this period.