Effect of an Evidence-Based Mobility Intervention on the Level of Function in Acute Intracerebral and Subarachnoid Hemorrhagic Stroke Patients on a Neurointensive Care Unit

Three Pillars of Recovery After Aneurysmal Subarachnoid Hemorrhage: A Narrative Review

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurologic disease with high mortality and disability. There have been global improvements in survival, which has contributed to the prevalence of patients living with long-term sequelae related to this disease. The focus of active research has traditionally centered on acute treatment to reduce mortality, but now there is a great need to study the course of short- and long-term recovery in these patients. In this narrative review, we aim to describe the core pillars in the preservation of cerebral function, prevention of complications, the recent literature studying neuroplasticity, and future directions for research to enhance recovery outcomes following aSAH.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage.

METHODS

A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Prognosis of Individual-Level Mobility and Daily Activities Recovery From Acute Care to Community, Part 2: A Proof-of-Concept Single Group Prospective Cohort Study

OBJECTIVE

To demonstrate a proof-of-concept for prognostic models of post-stroke recovery on activity level outcomes.

DESIGN

Longitudinal cohort with repeated measures from acute care, inpatient rehabilitation, and post-discharge follow-up to 6 months post-stroke.

SETTING

Enrollment from a single Midwest USA inpatient rehabilitation facility with community follow-up.

PARTICIPANTS

One-hundred fifteen persons recovering from stroke admitted to an acute rehabilitation facility (N=115).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Activity Measure for Post-Acute Care Basic Mobility and Daily Activities domains administered as 6 Clicks and patient-reported short forms.

RESULTS

The final Basic Mobility model defined a group-averaged trajectory rising from a baseline (pseudo-intercept) T score of 35.5 (P<.001) to a plateau (asymptote) T score of 56.4 points (P<.001) at a negative exponential rate of -1.49 (P<.001). Individual baseline scores varied by age, acute care tissue plasminogen activator, and acute care length of stay. Individual plateau scores varied by walking speed, acute care tissue plasminogen activator, and lower extremity Motricity Index scores. The final Daily Activities model defined a group-averaged trajectory rising from a baseline T score of 24.5 (P<.001) to a plateau T score of 41.3 points (P<.001) at a negative exponential rate of -1.75 (P<.001). Individual baseline scores varied by acute care length of stay, and plateau scores varied by self-care, upper extremity Motricity Index, and Berg Balance Scale scores.

CONCLUSIONS

As a proof-of-concept, individual activity-level recovery can be predicted as patient-level trajectories generated from electronic medical record data, but models require attention to completeness and accuracy of data elements collected on a fully representative patient sample.

A Step Forward for Intensive Care Unit Patients: Early Mobility Interventions and Associated Outcome Measures

Background

Critical illness survivors have impairments across physical, psychological, and cognitive health domains known as post–intensive care syndrome. Although physical activity can improve outcomes across all health domains, most intensive care unit early mobility studies focus solely on physical outcomes.

Objective

To explore the role of early mobility for adult patients in the intensive care unit by analyzing early mobility intervention studies with physical, psychological, or cognitive outcome measures.

Methods

This integrative review used Whittemore and Knafl’s methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. CINAHL, Embase, PubMed, PsycINFO, and Scopus databases were searched for primary research articles published from 2005 through 2021 on adult intensive care unit early mobility interventions evaluated by physical, cognitive, or psychological outcome measures during or after intervention delivery. Interventions comprising only passive mobility were excluded.

Results

Of 1009 articles screened, 20 were included. Variations in outcome measures, measurement timing, instruments, and control groups made synthesis difficult. No study evaluated an intervention using outcome measures from all 3 health domains. Five studies measured physical and cognitive outcomes; 6 studies measured physical and psychological outcomes.

Conclusion

Early mobility is primarily addressed objectively and unidimensionally, limiting understanding of the implications of early mobility for patients. Post–intensive care syndrome prevention begins in the intensive care unit; early mobility is a promising intervention for targeting multiple risk factors. Studies that measure outcomes in all health domains during or after early mobility are needed to better evaluate the comprehensive effects of early mobility.

Validity and Usefulness of an Electronic Health Care Record-Generated Mobility Ambulation Tool: The Human Body Was Designed to Move

BACKGROUND

Mobility is a vital function of human life. Nurses have an essential role in preventing hospitalized patient complications through movement and ambulation.

PURPOSE

This study examined the integration, accuracy, and precision of a paper-based mobility/ambulation tool into an electronic health record (EHR) to assess inpatient mobility/ambulation status.

METHODS

This multisite mixed-methods study was a time-series correlational evaluation of a mobility/ambulation tool into the EHR.

RESULTS

Sustainability data revealed strong correlations between nurse responses and EHR levels (r = 0.602; scores r = 0.624). Cronbach's α values were 0.737 and 0.761. Nurses' anecdotes supported the findings.

CONCLUSION

Findings revealed that the EHR-Mobility Ambulation Tool is a valid, reliable, and stable tool. EHR-generated scores can assist in reducing charting burden, care planning, and inform the interdisciplinary health team at all patient care stages. Tool adoption could potentially assist nurses plan interventions suitable to maintain or increase hospitalized patients' mobility status and contribute to discharge planning.

Rehabilitating the neurological patient in the ICU: what is important?

PURPOSE OF REVIEW

To describe recent literature evaluating the effectiveness of early rehabilitation in neurocritical care patients.

RECENT FINDINGS

There is a drive for early rehabilitation within the ICU; however, there are unique considerations for the neurocritically ill patient that include hemiplegia, cognitive impairments and impaired conscious state that can complicate rehabilitation. Additionally, neurological complications, such as hemorrhage expansion and cerebral edema can lead to the risk of further neurological damage. It is, therefore, important to consider the effect of exercise and position changes on cerebral hemodynamics in patients with impaired cerebral autoregulation. There is a paucity of evidence to provide recommendations on timing of early rehabilitation postneurological insult. There are also mixed findings on the effectiveness of early mobilization with one large, multicenter RCT demonstrating the potential harm of early and intensive mobilization in stroke patients. Conversely, observational trials have found early rehabilitation to be well tolerated and feasible, reduce hospital length of stay and improve functional outcomes in neurological patients admitted to ICU.

SUMMARY

Further research is warranted to determine the benefits and harm of early rehabilitation in neurological patients. As current evidence is limited, and given recent findings in stroke studies, careful consideration should be taken when prescribing exercises in neurocritically ill patients.

Early Mobilization of Mild-Moderate Intracerebral Hemorrhage Patients in a Stroke Center: A Randomized Controlled Trial

Background. Few studies have addressed early out-of-bed mobilization specifically in acute intracerebral hemorrhage (ICH) patients. Patient benefit in such cases is unclear, with early intervention timing and duration identical to those in standard care. Objective. We investigated the efficacy of an early mobilization (EM) protocol, administered within 24 to 72 hours of stroke onset, for early functional independence in mild-moderate ICH patients. Methods. Sixty patients admitted to a stroke center within 24 hours of ICH were randomly assigned to early mobilization (EM) or standard early rehabilitation (SER). The EM group underwent an early out-of-bed mobilization protocol, while the SER group underwent a standard protocol focusing on in-bed training in the stroke center. Intervention in both groups lasted 30 minutes per session, once a day, 5 days a week. Motor subscales of the Functional Independence Measure (FIM-motor; primary outcome), Postural Assessment Scale for Stroke Patients, and Functional Ambulation Category (FAC) were evaluated (assessor-blinded) at baseline, and at 2 weeks, 4 weeks, and 3 months after stroke. Length of stay in the stroke center was also recorded. Results. The EM group showed significant improvement in FIM-motor score at all evaluated time points (P = .004) and in FAC outcomes at 2 weeks (P = .033) and 4 weeks (P = .011) after stroke. Length of stay in the stroke center was significantly shorter for the EM group (P = .004). Conclusion. Early out-of-bed mobilization via rehabilitation in a stroke center, within 24 to 72 hours of ICH, may improve early functional independence compared with standard early rehabilitation. Clinical Trial Registration: NCT03292211.

Physiotherapy in the neurotrauma intensive care unit: A scoping review

PURPOSE

This scoping review summarizes the literature on the safety and effectiveness of physiotherapy interventions in patients with neurological and/or traumatic injuries in the intensive care unit (ICU), identifies literature gaps and provides recommendations for future research.

MATERIALS AND METHODS

We searched five databases from inception to June 2, 2018. We included published retrospective studies, case studies, observation and randomized controlled trials describing physiotherapy interventions in ICU patients with neurotrauma injuries. Two reviewers reviewed the databases and independently screened English articles for eligibility. Data extracted included purpose, study design, population (s), outcome measures, interventions and results. Thematic analysis and descriptive numerical summaries are presented by intervention type.

RESULTS

12,846 titles were screened and 72 met the inclusion criteria. Most of the studies were observational studies (44 (61.1%)) and RCTs (14 (19.4%)). Early mobilization, electrical stimulation, range of motion, and chest physiotherapy techniques were the most common interventions in the literature. Physiotherapy interventions were found to be safe with few adverse events.

CONCLUSIONS

Gaps in the literature suggest that future studies require assessment of long term functional outcomes and quality of life, examination of homogenous populations and more robust methodologies including clinical trials and larger samples.

Increased physician and physical therapist communication is associated with earlier mobility and decreased length of stay in the cerebrovascular and trauma neuroscience population

OBJECT

Recent efforts in neurocritical care have emphasized optimal timing and employment of rehabilitation services. However, there is sparse literature on the effect of team approaches to the intensive care patient. The aim of this study was to evaluate the effect of increased coordination between a physical therapist and an attending cerebrovascular neurosurgeon through daily multidisciplinary rounds.

METHODS

A retrospective review was performed of 235 patients who were admitted to the neuroscience service under a single cerebrovascular neurosurgeon over a 16-month period (April 2014 through July 2015) in a level-I trauma hospital. The study consisted of an eight-month pre-intervention period (n = 117) where the physical therapist did not attend physician rounds and an eight-month post-intervention period (n = 118).

RESULTS

In the post-intervention group the physical therapy (PT) assessment occurred on average 1.57 days sooner (p < 0.001). Hospital Length of Stay (LOS) decreased by an average of 3.46 days (p = 0.04) and ICU LOS decreased on average by 1.83 days (p = 0.05) in the post-intervention group. Ventilator days decreased on average by 0.55 days, which was not statistically significant (p = 0.26).

CONCLUSIONS

In conclusion, daily coordination with multidisciplinary rounds between the physician and the physical therapist was associated with decreased time to initial PT assessment, decreased hospital LOS, and decreased ICU LOS in the neuroscience population.

Four birds with one stone? Reparative, neuroplastic, cardiorespiratory, and metabolic benefits of aerobic exercise poststroke

PURPOSE OF REVIEW

Converging evidence from animal models of stroke and clinical trials suggests that aerobic exercise has effects across multiple targets.

RECENT FINDINGS

The subacute phase is characterized by a period of heightened neuroplasticity when aerobic exercise has the potential to optimize recovery. In animals, low intensity aerobic exercise shrinks lesion size and reduces cell death and inflammation, beginning 24 h poststroke. Also in animals, aerobic exercise upregulates brain-derived neurotrophic factor near the lesion and improves learning. In terms of neuroplastic effects, clinical trial results are less convincing and have only examined effects in chronic stroke. Stroke patients demonstrate cardiorespiratory fitness levels below the threshold required to carry out daily activities. This may contribute to a 'neurorehabilitation ceiling' that limits capacity to practice at a high enough frequency and intensity to promote recovery. Aerobic exercise when delivered 2-5 days per week at moderate to high intensity beginning as early as 5 days poststroke improves cardiorespiratory fitness, dyslipidemia, and glucose tolerance.

SUMMARY

Based on the evidence discussed and applying principles of periodization commonly used to prepare athletes for competition, we have created a model of aerobic training in subacute stroke in which training is delivered in density blocks (duration × intensity) matched to recovery phases.

The Economic and Clinical Impact of Sustained Use of a Progressive Mobility Program in a Neuro-ICU

OBJECTIVE

To investigate a progressive mobility program in a neurocritical care population with the hypothesis that the benefits and outcomes of the program (e.g., decreased length of stay) would have a significant positive economic impact.

DESIGN

Retrospective analysis of economic and clinical outcome data before, immediately following, and 2 years after implementation of the Progressive Upright Mobility Protocol Plus program (UF Health Shands Hospital, Gainesville, FL) involving a series of planned movements in a sequential manner with an additional six levels of rehabilitation in the neuro-ICU at UF Health Shands Hospital.

SETTING

Thirty-bed neuro-ICU in an academic medical center.

PATIENTS

Adult neurologic and neurosurgical patients: 1,118 patients in the pre period, 731 patients in the post period, and 796 patients in the sustained period.

INTERVENTIONS

Implementation of Progressive Upright Mobility Protocol Plus.

MEASUREMENTS AND MAIN RESULTS

ICU length of stay decreased from 6.5 to 5.8 days in the immediate post period and 5.9 days in the sustained period (F(2,2641) = 3.1; p = 0.045). Hospital length of stay was reduced from 11.3 ± 14.1 days to 8.6 ± 8.8 post days and 8.8 ± 9.3 days sustained (F(2,2641) = 13.0; p < 0.001). The impact of the study intervention on ICU length of stay (p = 0.031) and hospital length of stay (p < 0.001) remained after adjustment for age, sex, diagnoses, sedation, and ventilation. Hospital-acquired infections were reduced by 50%. Average total cost per patient after adjusting for inflation was significantly reduced by 16% (post period) and 11% (sustained period) when compared with preintervention (F(2,2641) = 3.1; p = 0.045). Overall, these differences translated to an approximately $12.0 million reduction in direct costs from February 2011 through the end of 2013.

CONCLUSIONS

An ongoing progressive mobility program in the neurocritical care population has clinical and financial benefits associated with its implementation and should be considered.

AMOBES (Active Mobility Very Early After Stroke): A Randomized Controlled Trial

BACKGROUND AND PURPOSE

Intensive physical therapy (PT) facilitates motor recovery when provided during a subacute stage after stroke. The efficiency of very early intensive PT has been less investigated. We aimed to investigate whether intensive PT conducted within the first 2 weeks could aid recovery of motor control.

METHODS

This multicentre randomized controlled trial compared soft PT (20-min/d apart from respiratory needs) and intensive PT (idem+45 minutes of intensive exercises/day) initiated within the first 72 hours after a first hemispheric stroke. The primary outcome was change in motor control between day (D) 90 and D0 assessed by the Fugl-Meyer score. Main secondary outcomes were number of days to walking 10 m unassisted, balance, autonomy, quality of life, and unexpected medical events. All analyses were by intent to treat.

RESULTS

We could analyze data for 103 of the 104 included patients (51 control and 52 experimental group; 64 males; median age overall 67 [interquartile range 59-77], 67 right hemispheric lesions, 80 ischemic lesions, National Institutes of Health Stroke Scale score ≥8 for 82%). Fugl-Meyer score increased over time (P<0.0001), with no significant effect of treatment (P=0.29) or interaction between treatment and time (P=0.40). The median change in score between D90 and D0 was 27.5 (12-40) and 22.0 (12-56) for control and experimental groups (P=0.69). Similar results were found for the secondary criteria.

CONCLUSIONS

Very early after stroke, intensive exercises may not be efficient in improving motor control. This conclusion may apply to mainly severe stroke.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01520636.

Mobilization of patients in neurological Intensive Care Units of India: A survey

Context:

The rehabilitation needs of the patients in neurological Intensive Care Units (ICUs) vary from that of a medical ICU patient. Early mobilization is known to improve the various neurological outcomes in patients admitted to neurological ICUs, although little is known about the practice pattern among physiotherapists. The mobilization practice pattern may vary significantly than that of developed countries due to the reasons of differences in training of professionals, availability of equipment, and financial assistance by health insurance.

Aim of the Study:

To study the current mobilization practices by the physiotherapists in neurological ICUs of India.

Subjects and Methods:

A cross-sectional survey was conducted with a content validated questionnaire about the mobilization practices. Online questionnaire was distributed to physiotherapists working in neurological ICUs of India. Descriptive statistics were used.

Results:

Out of 185 e-mails sent, 82 physiotherapists completed the survey (survey response rate = 44%). Eighty participants (97.6%) mentioned that the patients received some form of mobilization during the day. The majority of the physiotherapists (58.5%), “always” provided bed mobility exercises to their patients when it was found appropriate for the patients. Many physiotherapists (41.5%) used tilt table “sometimes” to introduce orthostatism for their patients.

Conclusion:

Mobilization in various forms is being practiced in the neurological ICUs of India. However, fewer mobilization sessions are conducted on weekends and night hours in Indian Neurological ICUs.