MedicalResearch.com Interview with:
Craig Anderson | MD PhD FRACP
Professor of Neurology and Epidemiology, Faculty of Medicine, UNSW Sydney
Neurologist, Neurology Department, Royal Prince Alfred Hospital
The George Institute for Global Health at Peking University Health Science Center
Haidian District | Beijing, 100088 P.R. China
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: Preliminary small studies indicate that lying flat increases blood flow and oxygenation to the brain. Thus, patients with acute ischemic stroke may benefit from lying flat in bed. Conversely, sitting up in bed, with the head elevated to at least 30 degrees, may reduce swelling in the brain for patients who have large ischemic or hemorrhagic forms of stroke. The optimal head position to produce the best outcome from acute stroke, and avoid potential risks, such as aspiration pneumonia, is unknown. We undertook a large scale multicentre randomized controlled trial where 114 hospitals were randomised to sequentially apply lying flat or sitting up head positioning as a policy of care to a consecutive series of patients, that overall totalled over 11000 patients, presenting with acute stroke. The study showed there was no difference in the chance of good physical recovery for patients between the two head positions but also that there were no excessive harms for either.
In other words, head positioning alone didn’t produce any benefits or harms in patients with acute stroke
MedicalResearch.com: What should clinicians and patients take away from your report?
Response: These data do not indicate there should be a policy for specific head positioning in acute stroke, and that positioning of the head of the patient does not produce any specific risks such as aspiration pneumonia or cardiorespiratory compromise. Nursing care should focus on specific vital signs and other parameters of management, and the optimal head position for stroke patients is that which is most comfortable and suitable for delivery of care.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: As in all clinical trials, there are less patients in specific subgroups who may derive more benefit (or harm) from the intervention under investigation. In this study, there were fewer patients with strokes due to proximal large cerebral vessel occlusion with associated potential large ischemic region in the cerebral hemisphere who presented early, and those with severe stroke requiring intubation and intensive care management. Both of these types of patients may require further research as to the optimal head position, although there are significant challenges to the conduct of a clinical trial in these situations.
MedicalResearch.com: Is there anything else you would like to add?
Response: Head positioning in clinical practice varies around the world dependent on cultural beliefs over blood flow to the brain, the uptake of national guideline recommendations, and the sophistication of mechanical beds that allow adjustment of the head of the bed. This research should harmonise clinical practice and guideline recommendation policy.
No relevant disclosures.
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N Engl J Med 2017; 376:2437-2447
June 22, 2017DOI: 10.1056/NEJMoa1615715
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