NIHR Signal Head position after acute stroke does not affect disability outcomes

Published on 3 October 2017

Lying flat for 24 hours after a stroke is no better than sitting up at an angle of at least 30 degrees. These differences in early head position did not affect people’s levels of disability or survival to 90 days, which was more than 92% in both groups. It had been thought that the head down position might increase the chance of pneumonia, but in this trial, the rates were also similar for people cared for in either position.

The results of this large international randomised controlled trial are likely to be applicable to adults with different types of stroke in varied settings. As lying position did not affect outcomes, this suggests that clinicians can be guided by patients’ clinical condition, preferences and levels of comfort during the initial management of care.

The current NICE guideline on diagnosis and initial management of stroke suggests that people with acute stroke should be helped to sit up as soon as possible (when their clinical condition permits).

Head position after acute stroke does not affect disability outcomes

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Why was this study needed?

A stroke occurs when the blood (and therefore oxygen) supply to part of the brain is cut off. Over 80,000 people in England and Wales are admitted to hospital with an acute stroke each year. Disability following stroke is very common: after six months, 40% of people have difficulty with basic self-care such as dressing and feeding.

The evidence about whether lying patients flat on their backs following stroke is better than sitting them up has been inconclusive. Lying horizontally with the face upwards may increase blood and oxygen flow to the brain. On the other hand, sitting up with the head raised may reduce both pressure on the brain in patients with large strokes, and the risk of aspiration pneumonia - a common complication following a stroke.  

This study aimed to compare the effects of these positions, to help determine which one should be used in practice.

What did this study do?

The Head Positioning in Acute Stroke Trial (HeadPoST) included 11,093 adults with acute stroke from 114 hospitals in nine countries. This included 4,160 patients from 41 hospitals in the UK. Hospitals were randomised to have patients either lie horizontally or to sit up with their head elevated for 24 hours, starting as soon as possible after admission. Each hospital switched to using the other positioning after a specified number of patients had been treated.

This was a well-designed trial, with reliable results. Its findings are likely to be applicable in practice, as it included patients with different types of stroke, and the participating hospitals covered a range of settings (such as rural and urban, public and private).

What did it find?

  • Head position did not significantly affect disability as assessed on the modified Rankin scale at 90 days (odds ratio [OR] for comparison of overall score distribution 1.01, 95% confidence interval [CI] 0.92 to 1.10). In the lying-flat group, 30.8% of the patients had major disability (not including death) at 90 days, compared to 31.4% of the patients in the sitting-up group.
  • Head position also did not affect the risk of death within 90 days after stroke. In the lying-flat group, 7.3% of patients died compared to 7.4% in the sitting-up group (OR 0.98, 95% CI 0.85 to 1.14).
  • There was no difference in the proportion of patients developing pneumonia between the groups: 3.1% in the lying-flat group versus 3.4% in the sitting-up group (OR 0.86, 95% CI 0.68 to 1.08).
  • While lying flat improved overall health-related quality of life at 90 days, this effect was small (average 1.4 points on the 100 European Quality of Life Group 5-Dimension Self-Report Questionnaire [EQ-5D] visual analogue scale). There were no differences in quality of life in the five subdomains assessed - mobility, self-care, usual activities, pain and discomfort, or anxiety and depression.
  • Patients in the lying-flat group were more likely to discontinue their assigned position: 13.1% stopped compared with 4.2% in the sitting-up group (OR 4.0, 95% CI 3.1 to 5.3). The most common reason was that they could not tolerate lying flat (28.9% of discontinuations).

What does current guidance say on this issue?

NICE’s 2008 guideline on the diagnosis and initial management of stroke in the over 16s has a section on early mobilisation and optimum positioning of people with acute stroke. It recommends that people who have experienced a stroke should be helped to sit up as soon as their clinical condition permits. It suggests that this will help to maintain blood oxygen levels and reduce the likelihood of pneumonia.

This guideline is due to have a partial update published in 2019.

What are the implications?

Current practice varies around positioning stroke patients during their early management. The results of this large, well-designed trial should be taken note of. It shows that lying flat has no important benefits over sitting up. This may mean that clinicians should be guided by patients’ clinical condition and preferences in this period.

The assigned head positions were adopted a median of 14 hours after stroke (interquartile range five to 35 hours), and it is possible that results might differ if they were adopted sooner. However, it may be difficult to achieve this in regular clinical practice.

This evidence might inform future updates to the NICE guideline, but is an area where patient and clinician choice can now be guided by “strong evidence of no difference”.

Citation and Funding

Anderson CS, Arima H, Lavados P, et al; HeadPoST Investigators and Coordinators. Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke. N Engl J Med. 2017;376(25):2437-47

This project was funded by the National Health and Medical Research Council of Australia.

Bibliography

NHS Choices. Stroke. London: Department of Health; 2016.

NICE CKS. Stroke and TIA. London: National Institute for Health and Care Excellence Clinical Knowledge Summaries; 2017.

NICE. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. CG68. London: National Institute for Health and Care Excellence; 2008.

Why was this study needed?

A stroke occurs when the blood (and therefore oxygen) supply to part of the brain is cut off. Over 80,000 people in England and Wales are admitted to hospital with an acute stroke each year. Disability following stroke is very common: after six months, 40% of people have difficulty with basic self-care such as dressing and feeding.

The evidence about whether lying patients flat on their backs following stroke is better than sitting them up has been inconclusive. Lying horizontally with the face upwards may increase blood and oxygen flow to the brain. On the other hand, sitting up with the head raised may reduce both pressure on the brain in patients with large strokes, and the risk of aspiration pneumonia - a common complication following a stroke.  

This study aimed to compare the effects of these positions, to help determine which one should be used in practice.

What did this study do?

The Head Positioning in Acute Stroke Trial (HeadPoST) included 11,093 adults with acute stroke from 114 hospitals in nine countries. This included 4,160 patients from 41 hospitals in the UK. Hospitals were randomised to have patients either lie horizontally or to sit up with their head elevated for 24 hours, starting as soon as possible after admission. Each hospital switched to using the other positioning after a specified number of patients had been treated.

This was a well-designed trial, with reliable results. Its findings are likely to be applicable in practice, as it included patients with different types of stroke, and the participating hospitals covered a range of settings (such as rural and urban, public and private).

What did it find?

  • Head position did not significantly affect disability as assessed on the modified Rankin scale at 90 days (odds ratio [OR] for comparison of overall score distribution 1.01, 95% confidence interval [CI] 0.92 to 1.10). In the lying-flat group, 30.8% of the patients had major disability (not including death) at 90 days, compared to 31.4% of the patients in the sitting-up group.
  • Head position also did not affect the risk of death within 90 days after stroke. In the lying-flat group, 7.3% of patients died compared to 7.4% in the sitting-up group (OR 0.98, 95% CI 0.85 to 1.14).
  • There was no difference in the proportion of patients developing pneumonia between the groups: 3.1% in the lying-flat group versus 3.4% in the sitting-up group (OR 0.86, 95% CI 0.68 to 1.08).
  • While lying flat improved overall health-related quality of life at 90 days, this effect was small (average 1.4 points on the 100 European Quality of Life Group 5-Dimension Self-Report Questionnaire [EQ-5D] visual analogue scale). There were no differences in quality of life in the five subdomains assessed - mobility, self-care, usual activities, pain and discomfort, or anxiety and depression.
  • Patients in the lying-flat group were more likely to discontinue their assigned position: 13.1% stopped compared with 4.2% in the sitting-up group (OR 4.0, 95% CI 3.1 to 5.3). The most common reason was that they could not tolerate lying flat (28.9% of discontinuations).

What does current guidance say on this issue?

NICE’s 2008 guideline on the diagnosis and initial management of stroke in the over 16s has a section on early mobilisation and optimum positioning of people with acute stroke. It recommends that people who have experienced a stroke should be helped to sit up as soon as their clinical condition permits. It suggests that this will help to maintain blood oxygen levels and reduce the likelihood of pneumonia.

This guideline is due to have a partial update published in 2019.

What are the implications?

Current practice varies around positioning stroke patients during their early management. The results of this large, well-designed trial should be taken note of. It shows that lying flat has no important benefits over sitting up. This may mean that clinicians should be guided by patients’ clinical condition and preferences in this period.

The assigned head positions were adopted a median of 14 hours after stroke (interquartile range five to 35 hours), and it is possible that results might differ if they were adopted sooner. However, it may be difficult to achieve this in regular clinical practice.

This evidence might inform future updates to the NICE guideline, but is an area where patient and clinician choice can now be guided by “strong evidence of no difference”.

Citation and Funding

Anderson CS, Arima H, Lavados P, et al; HeadPoST Investigators and Coordinators. Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke. N Engl J Med. 2017;376(25):2437-47

This project was funded by the National Health and Medical Research Council of Australia.

Bibliography

NHS Choices. Stroke. London: Department of Health; 2016.

NICE CKS. Stroke and TIA. London: National Institute for Health and Care Excellence Clinical Knowledge Summaries; 2017.

NICE. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. CG68. London: National Institute for Health and Care Excellence; 2008.

Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke

Published on 22 June 2017

Anderson, C. S.,Arima, H.,Lavados, P.,Billot, L.,Hackett, M. L.,Olavarria, V. V.,Munoz Venturelli, P.,Brunser, A.,Peng, B.,Cui, L.,Song, L.,Rogers, K.,Middleton, S.,Lim, J. Y.,Forshaw, D.,Lightbody, C. E.,Woodward, M.,Pontes-Neto, O.,De Silva, H. A.,Lin, R. T.,Lee, T. H.,Pandian, J. D.,Mead, G. E.,Robinson, T.,Watkins, C.

N Engl J Med Volume 376 Issue 25 , 2017

BACKGROUND: The role of supine positioning after acute stroke in improving cerebral blood flow and the countervailing risk of aspiration pneumonia have led to variation in head positioning in clinical practice. We wanted to determine whether outcomes in patients with acute ischemic stroke could be improved by positioning the patient to be lying flat (i.e., fully supine with the back horizontal and the face upwards) during treatment to increase cerebral perfusion. METHODS: In a pragmatic, cluster-randomized, crossover trial conducted in nine countries, we assigned 11,093 patients with acute stroke (85% of the strokes were ischemic) to receive care in either a lying-flat position or a sitting-up position with the head elevated to at least 30 degrees, according to the randomization assignment of the hospital to which they were admitted; the designated position was initiated soon after hospital admission and was maintained for 24 hours. The primary outcome was degree of disability at 90 days, as assessed with the use of the modified Rankin scale (scores range from 0 to 6, with higher scores indicating greater disability and a score of 6 indicating death). RESULTS: The median interval between the onset of stroke symptoms and the initiation of the assigned position was 14 hours (interquartile range, 5 to 35). Patients in the lying-flat group were less likely than patients in the sitting-up group to maintain the position for 24 hours (87% vs. 95%, P<0.001). In a proportional-odds model, there was no significant shift in the distribution of 90-day disability outcomes on the global modified Rankin scale between patients in the lying-flat group and patients in the sitting-up group (unadjusted odds ratio for a difference in the distribution of scores on the modified Rankin scale in the lying-flat group, 1.01; 95% confidence interval, 0.92 to 1.10; P=0.84). Mortality within 90 days was 7.3% among the patients in the lying-flat group and 7.4% among the patients in the sitting-up group (P=0.83). There were no significant between-group differences in the rates of serious adverse events, including pneumonia. CONCLUSIONS: Disability outcomes after acute stroke did not differ significantly between patients assigned to a lying-flat position for 24 hours and patients assigned to a sitting-up position with the head elevated to at least 30 degrees for 24 hours. (Funded by the National Health and Medical Research Council of Australia; HeadPoST ClinicalTrials.gov number, NCT02162017 .).

Modified Rankin Scale is a scale which measures disability on a scale from zero to six, with zero indicating no symptoms, and six indicating death. Major disability (not including death) is defined as a score of between three and five.

Expert commentary

The HeadPoST study is a good example of how important questions related to everyday NHS care of stroke patients should be examined and not taken for granted. Being involved in this trial I believe there were issues with the variance between mobile and immobile patients, types of strokes and past medical history. I witnessed some non-compliance from patients e.g. using the bathroom; however, this data was captured.

The results of the trial did not differ significantly with either head position; neither mortality nor rates of pneumonia were affected. This study has answered a long-standing question in stroke care - to my surprise this element of care continues to differ across the world.

Maria Fitzpatrick, Lead Hyper Acute Consultant Stroke Nurse for South East London, Denmark Hill and PRUH Sites, Kings College NHS Foundation Trust and Pan London Representative for the Stroke Strategic Clinical Leadership Group