The George Institute For Global Health
United Kingdom

Head Position in Stroke Trial (HeadPoST)

Project status: 
Start date: 
Fact sheet

The HeadPoST trial has revealed sitting up or lying flat after a stroke in fact makes no difference to a person’s recovery. The trial was designed to resolve uncertainty and provide reliable evidence over the optimum head position for recovery when a person suffers an acute ischaemic stroke or an intracerebral haemorrhage. 

The George Institute for Global Health led the trial of over 11,000 patients in 114 hospitals in 9 countries. The aim was to discover whether one head position (raised or lying flat) reduced death or disability for people with the most common form of stroke (ischaemic). Some previous studies had indicated lying flat may improve recovery by increasing blood flow in the main arteries to the brain. However, there were fears it also raised the risks of pneumonia. The results published in the New England Journal of Medicine show that while the position of a patient’s head does not affect outcomes (good or bad), lying flat was less tolerated and more uncomfortable than sitting up.


Stroke is a major cause of global disease burden for which there are limited therapies. Most strokes (~80%) are ischaemic in nature caused by acute occlusion (‘clot’) of an artery which leads to an immediate reduction in blood flow within the corresponding cerebrovascular territory. In acute ischaemic stroke, the size and site of the occlusion and the efficiency of compensatory collateral blood flow, determine the extent of ‘at risk’ (‘ischaemic penumbra’) and/or dead (‘infarcted’) brain. 

Although the body’s natural fibrinolytic system is designed to dissolve newly formed clot, this is inadequate for most people with AIS as the clots are often large. Modern thrombolytic treatment with recombinant tissue plasminogen activator aims to rapidly dissolve clots and recanalise the blocked vessel to reperfuse the ischaemic penumbra, preserve brain function and promote a good outcome for patients.


HeadPoST was an investigator-initiated and conducted, international collaborative, regionally organised, multicentre, prospective, cluster randomised crossover blinded outcome assessment study to compare the effectiveness of the lying flat (0°) head position with the sitting up (≥30°) head position, in the first 24 hours of admission to hospital for patients with acute stroke, on the outcome of death or disability over the subsequent 90 days. Over a hundred sites participated in HeadPoST. 

Features of the study included the use of:

  1. A simple nursing intervention evaluated on a large scale
  2. An established research infrastructure and global clinical network for ongoing large-scale academic stroke trials
  3. Broad inclusion criteria and conduct of the study across different health care settings to support the generalisability of results
  4. A crossover design so that all hospital sites receive both randomised interventions which will control for the confounding influence of background care and organisation change; and 
  5. A prespecified and published statistical analysis plan​

Read this British Medical Journal article on HeadPOST

Current status

Trial complete with analyses and research publications in process.