Lying flat, sitting up similar for mild and moderate stroke recovery

Head position doesn’t matter when patients are recovering from a mild to moderate stroke. The first head-to-head trial of lying flat versus sitting up showed no statistically or clinically significant differences in death or disability 90 days after admission between the two positions.

“The lying-flat position has been suggested to offer benefits to patients with acute ischemic stroke based on nonrandomized studies that suggest increased blood flow in the major vessels and increased perfusion in the cerebral hemispheres,” said Craig Anderson, MD, PhD, executive director of The George Institute for Global Health in Sydney, Australia.

“The sitting position may reduce cerebral edema in large strokes, as has been suggested in patients with head injury,” he said. “There was no difference in any of the measures of disability, but conversely, we didn’t show any extra harms. We didn’t find any extra risk of pneumonia.”

Anderson presented the results of the Head Position in Stroke Trial (HeadPoST) at the International Stroke Conference in Houston. The nursing intervention trial compared the unadjusted shift in modified Rankin Score or mRS 90 days after admission for acute stroke in more than 11,000 patients across 114 hospitals in nine countries between March 2015 and August 2016.

Secondary outcomes included a binary shift in mRS of 0-2 and 3-6, total length of hospital stay at 90 days after the initial admission, and shifts in NIHSS scores and death at seven days. Safety endpoints were any serious adverse event, especially pneumonia. The trial design included several prespecified subgroups, including sex, age, country of admission, severity by NIHSS, ischemic stroke subtype and time to intervention.

HeadPoST used a novel multicenter cluster crossover design in which hospitals were randomized to treat clusters of 70 consecutive patients in either a lying-down or sitting-up position, then switching to the other position for the next cluster of 70 patients. Patients were kept in the assigned position for the first 24 hours unless there was a contraindication or patients were unable to tolerate the position.

Patients in the trial had mild to moderate strokes with a median NIHSS of just four and the highest score below 10. Most patients were in their late 60s and had the typical risk factors for stroke, Anderson said. They were admitted a mean of 14 hours after onset, and 12 percent received tPA.

There has been no consensus on the more appropriate position for acute stroke patients, Anderson noted. The lying-down position is more often used in resource-poor hospitals that may have a shortage of elevated beds that allow easier patient positioning.

The use of the lying-down position has become more popular in the West as a way to offer perceived benefits of reperfusion as suggested by transcranial Doppler studies. At the same time, there have been suggestions that the supine position increases risk for aspiration pneumonia.

Current AHA/ASA guidelines for the early management of acute ischemic stroke recommend the lying-down position for the early treatment of patients with acute ischemic stroke who are not hypoxic, but only if the patient tolerates the lying-down position. The guidelines also recommend sitting up at 30o or higher for patients at risk for airway obstruction or suspected elevated intracranial pressure.

The trial found no differences in mRS 90 days after admission between the two strategies (OR 1.01, p=0.84) or in any other outcomes. The only clinically significant difference between the two positions was the time spent in the allocated position. Patients were four times more likely to abandon the lying-down position because it was uncomfortable (p<0.0001).

“We have been successful in evaluating a simple nursing intervention,” Anderson said. “We can’t make any clear recommendations regarding benefits or harms for head positioning in acute stroke. This may lead to review of various guidelines.”