Very early versus early exercise rehabilitation after intracerebral hemorrhage

BACKGROUND: The optimal timing of rehabilitation initiation after intracerebral hemorrhage (ICH) remains uncertain. This systematic review and meta-analysis compared the efficacy and safety of very early versus early exercise rehabilitation after ICH. METHODS: Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Chinese Science and Technology Journal Database/VIP Database, Wanfang, PubMed, Embase, the Cochrane Library, Web of Science, ClinicalTrials.gov, and the Chinese Clinical Trial Registry were searched from inception to October 10, 2023. Randomized controlled trials comparing very early with early exercise rehabilitation after ICH were included. Two reviewers independently screened studies, extracted data, and assessed risk of bias. Continuous outcomes were pooled as mean differences (MDs) with 95% confidence intervals (CIs). Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. Primary outcomes included the National Institutes of Health Stroke Scale, Fugl-Meyer Assessment, Modified Barthel Index, and Barthel Index. RESULTS: Seventeen randomized controlled trials involving 1396 participants were included. Compared with early rehabilitation, very early rehabilitation was associated with better outcomes for National Institutes of Health Stroke Scale (MD = -3.89, 95% CI: -5.00 to -2.78), Fugl-Meyer Assessment (MD = 10.24, 95% CI: 6.80-13.68), Modified Barthel Index (MD = 0.92, 95% CI: 0.73-1.11), and Barthel Index (MD = 1.89, 95% CI: 1.70-2.08). Substantial heterogeneity was observed across the pooled analyses. Standardized safety outcomes, including rebleeding, hemodynamic instability, and falls, were insufficiently reported for quantitative synthesis. The certainty of evidence was low for all outcomes. CONCLUSION: In clinically stable patients with ICH, very early exercise rehabilitation may be associated with better neurological and functional recovery than rehabilitation initiated later within the early phase. However, the findings should be interpreted cautiously because of substantial heterogeneity, incomplete safety reporting, and low certainty of evidence.