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Patient Head Position After Stroke Doesn’t Appear to Affect Outcomes

With everything else emergency clinicians are trying to get right when treating patients presenting with probable stroke, here is something they don’t have to worry about: whether the patients sit up or lie flat.

Some studies and guidelines have suggested that blood flow to the brain is increased when patients are in prone position, although concerns have been raised about pneumonia risks. Now, an international trial involving more than 11,000 patients answers the question in a report published recently in the New England Journal of Medicine: In short, researchers insist that bed position really doesn’t seem to make much of a difference in recovery.

Australian researchers led by the George Institute for Global Health sought to determine if the position in bed could help reduce death or disability in patients with stroke; 85% of the cases were ischemic. The trial took place in 114 hospitals in Australia, Brazil, Chile, China, Colombia, India, Sri Lanka, Taiwan, and the UK.

“Many stroke specialists believe that the way the body is positioned after stroke makes a difference to their patient's recovery,” explained lead investigator Craig Anderson, PhD. “But there was really no conclusive evidence to back this up.”

For the trial, participants were assigned to receive care in either a lying-flat position or a sitting-up position, with the head elevated to at least 30 degrees. The designated position was initiated an average of 14 hours after stroke onset and maintained for 24 hours after hospital admission.


Results indicate no meaningful variation in Rankin scale 90-day disability outcomes between the two groups. 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, and no significant between-group differences in the rates of serious adverse events, including pneumonia, were documented.

“What we found is that head position does not matter so much over and above good nursing care. It does not help with recovery, with mortality, or how a patient feels,” Anderson noted. “However, we also found there were no significant harms associated with either lying down flat or sitting up.”

The findings indicate that the patients lying flat experienced greater discomfort and fewer of those patients could maintain the position for 24 hours than those sitting up – 87% vs. 95%.

Study authors also cautioned that their results might not be applicable in all cases, because most of the patients who took part in the study had mild to moderate severity strokes, with an average age of 68 years. They suggested, however, that current recommendations might be reconsidered.

“Our findings suggest a review of current clinical practice guidelines is warranted,” Anderson concluded.