Vascular disease

Lying down or sitting up? Head position after stroke does not affect outcomes

Debate about whether patients should be treated sitting up or lying flat in the first 24 hours following acute ischaemic stroke could finally be settled with new Australian research suggesting head position may not matter.

Concerns about the potential risks of cardiopulmonary dysfunction and aspiration pneumonia and the role of head positioning following acute ischaemic stroke had led to variation in clinical practice, said researchers from the George Institute for Global Health who led the trial published in the New England Journal of Medicine this month.

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

He says evidence from the HeadPoST trial now suggests that there are no significant differences between the two head positions in terms of mortality or the rate of serious adverse events, including pneumonia.

The study involving 11,000 patients took place at 114 hospitals in Australia, the UK, China, Taiwan, India, Sri Lanka, Chile, Brazil and Colombia.

Patients were either assigned to lie flat with their face upwards or with their head raised to at least 30 degrees during the first 24 hours following stroke.

While the trial found that lying flat was “uncomfortable” it didn’t appear to affect outcomes – there was no difference in outcomes between the head-up or head-down position regardless of the type or age of the patient, type and region of the stroke or time from symptom onset on assessment 90 days later.

“What we found is that patients found lying flat were somewhat uncomfortable, but it certainly didn’t make their condition any worse,” said lead researcher Professor Craig Anderson.

He argued that a review of current clinical practice guidelines is warranted.

“Head 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. However, we also found there were no significant harms associated with either lying down flat or sitting up.”

All the patients involved in the study had mostly mild to moderate neurologic severity caused by acute stroke and had undergone initial treatment to dissolve or remove the clot before being enrolled for the trial.

The authors acknowledged that earlier initiation of head position after the onset of symptoms ‘when the ischaemic penumbra is potentially modifiable’ could have produced different results.

But they added that the negative results of the trial suggest that any modification of blood flow to the brain that may have occurred as a result of head positioning in the first 24 hours was ‘insufficient to reduce the neurologic deficit associated with acute stroke’.

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