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

Motor Rehabilitation Provides Modest Functional Benefits After Intracerebral Hemorrhage: a Systematic Review and Meta-Analysis of Translational Rehabilitation Studies

Few certainties exist regarding the optimal type, timing, or dosage of rehabilitation after stroke. Despite differing injury mechanisms and recovery patterns following ischemic and hemorrhagic stroke, most translational stroke research is conducted after ischemia. As we enter the era of personalized medicine, exploring subtype-specific treatment efficacy is essential to optimizing recovery. Our objective was to characterize common rehabilitation interventions used after in vivo preclinical intracerebral hemorrhage (ICH) and assess the impact of post-ICH rehabilitation (vs. no-rehabilitation) on recovery of motor function. Following PRISMA guidelines, a systematic review (Academic Search Complete, CINAHL, EMBASE, Medline, PubMed Central) identified eligible articles published up to December 2022. Risk of bias (SYRCLE) and study quality (CAMARADES) were evaluated, and random-effects meta-analysis was used to assess treatment efficacy in recovery of forelimb and locomotor functions. Thirty articles met inclusion criteria, and 48 rehabilitation intervention groups were identified. Most used collagenase to model striatal ICH in young, male rodents. Aerobic exercise, enriched rehabilitation, and constraint-induced movement therapy represented ~ 70% of interventions. Study quality was low (median 4/10, range 2-8), and risk of bias was unclear. Rehabilitation provided modest benefits in skilled reaching, spontaneous impaired forelimb use, and locomotor function; however, effects varied substantially by endpoint, treatment type, and study quality. Rehabilitation statistically improves motor function after preclinical ICH, but whether these effects are functionally meaningful is unclear. Incomplete reporting and variable research quality hinder our capacity to analyze and interpret how treatment factors influence rehabilitation efficacy and recovery after ICH.

Efficacy and Safety of Early Mobilization and Factors Associated with Rehabilitation After Stroke-Review

Background/Objectives: Knowledge about the safety and effectiveness of early post-stroke mobilization and its correlation with various factors is necessary to select an appropriate rehabilitation program and reduce the time of convalescence. Understanding the above processes will help to effectively lower the economic burden. Thus, we conducted a review to assess the safety and effectiveness of early post-stroke rehabilitation and the impact of various factors on the course of therapy. Methods: The analysis included publications meeting the inclusion criteria published in the years 2015-2024 in Web of Science, Scopus, Embase, and PubMed. Finally, 12 studies were qualified for the review. The study group ranged from 37 to 2325 people. Results: The results of studies on early stroke mobilization indicate possible benefits, including reduced time of hospitalization and faster achievement of higher functional scores. It has been shown that the important factors correlating with the effectiveness of therapy include: rehabilitation intensity, age, functional status before the stroke, depression, social support, lesion location, lower extremity deep vein thrombosis, cognitive disorder, dysphagia, and lower limb spasticity. Conclusions: There is a strong need for research into post-stroke rehabilitation to speed up recovery times and reduce the economic burden on the country. Current research findings on the efficacy and safety of early rehabilitation are inconsistent. There is a strong need for international guidelines.

Safety of Early Mobilization in Adult Neurocritical Patients: An Exploratory Review

Introduction: Early mobilization has shown significant benefits in the rehabilitation of critically ill patients, including improved muscle strength, prevention of physical deconditioning, and reduced hospital length of stay. However, its safety in neurocritical patients, such as those with strokes, traumatic brain injuries, and postsurgical brain surgeries, remains uncertain. This study aims to map and examine the available evidence on the safety of early mobilization in adult neurocritical patients. Methods: A scoping review was conducted following PRISMA-SCR guidelines and the Joanna Briggs Institute (JBI) methodology. The research question focused on the safety of early mobilization in neurocritical patients, considering adverse events, neurological changes, hemodynamic changes, and respiratory changes. A comprehensive search was performed in databases such as PubMed, BVS-LILACS, Ovid MEDLINE, and ScienceDirect, using specific search strategies. The selected studies were assessed for methodological quality using JBI tools. Results: Of 1310 identified articles, 25 were included in the review. These studies comprised randomized controlled trials, prospective observational studies, retrospective studies, and pre- and postimplementation intervention studies. The review found that early mobilization in neurocritical patients is generally safe, with a low incidence of severe adverse events, and does not increase the risk of vasospasm, and most complications were manageable with protocol adjustments and continuous monitoring. Conclusion: Early mobilization in neurocritical patients has been shown to be potentially safe under specific conditions, without a significant increase in severe complications when properly monitored. However, the available evidence is limited by the heterogeneity of protocols and study designs, emphasizing the need for further research. The importance of tailoring mobilization protocols to each patient and ensuring continuous monitoring is highlighted. Additional studies with larger sample sizes are needed to fully understand the associated risks and optimize mobilization strategies.

Physical rehabilitation approaches for the recovery of function and mobility following stroke

BACKGROUND

Various approaches to physical rehabilitation to improve function and mobility are used after stroke. There is considerable controversy around the relative effectiveness of approaches, and little known about optimal delivery and dose. Some physiotherapists base their treatments on a single approach; others use components from several different approaches.

OBJECTIVES

Primary objective: To determine whether physical rehabilitation is effective for recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.

SECONDARY OBJECTIVE

To explore factors that may impact the effectiveness of physical rehabilitation approaches, including time after stroke, geographical location of study, intervention dose/duration, intervention provider, and treatment components. Stakeholder involvement: Key aims were to clarify the focus of the review, inform decisions about subgroup analyses, and co-produce statements relating to key implications.

SEARCH METHODS

For this update, we searched the Cochrane Stroke Trials Register (last searched November 2022), CENTRAL (2022, Issue 10), MEDLINE (1966 to November 2022), Embase (1980 to November 2022), AMED (1985 to November 2022), CINAHL (1982 to November 2022), and the Chinese Biomedical Literature Database (to November 2022).

SELECTION CRITERIA

Inclusion criteria: Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke.

EXCLUSION CRITERIA

RCTs of upper limb function or single treatment components.

PRIMARY OUTCOMES

measures of independence in activities of daily living (IADL) and motor function.

SECONDARY OUTCOMES

balance, gait velocity, and length of stay.

DATA COLLECTION AND ANALYSIS

Two independent authors selected studies according to pre-defined eligibility criteria, extracted data, and assessed the risk of bias in the included studies. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

In this review update, we included 267 studies (21,838 participants). Studies were conducted in 36 countries, with half (133/267) in China. Generally, studies were heterogeneous, and often poorly reported. We judged only 14 studies in meta-analyses as at low risk of bias for all domains and, on average, we considered 33% of studies in analyses of primary outcomes at high risk of bias. Is physical rehabilitation more effective than no (or minimal) physical rehabilitation? Compared to no physical rehabilitation, physical rehabilitation may improve IADL (standardised mean difference (SMD) 1.32, 95% confidence interval (CI) 1.08 to 1.56; 52 studies, 5403 participants; low-certainty evidence) and motor function (SMD 1.01, 95% CI 0.80 to 1.22; 50 studies, 5669 participants; low-certainty evidence). There was evidence of long-term benefits for these outcomes. Physical rehabilitation may improve balance (MD 4.54, 95% CI 1.36 to 7.72; 9 studies, 452 participants; low-certainty evidence) and likely improves gait velocity (SMD 0.23, 95% CI 0.05 to 0.42; 18 studies, 1131 participants; moderate-certainty evidence), but with no evidence of long-term benefits. Is physical rehabilitation more effective than attention control? The evidence is very uncertain about the effects of physical rehabilitation, as compared to attention control, on IADL (SMD 0.91, 95% CI 0.06 to 1.75; 2 studies, 106 participants), motor function (SMD 0.13, 95% CI -0.13 to 0.38; 5 studies, 237 participants), and balance (MD 6.61, 95% CI -0.45 to 13.66; 4 studies, 240 participants). Physical rehabilitation likely improves gait speed when compared to attention control (SMD 0.34, 95% CI 0.14 to 0.54; 7 studies, 405 participants; moderate-certainty evidence). Does additional physical rehabilitation improve outcomes? Additional physical rehabilitation may improve IADL (SMD 1.26, 95% CI 0.82 to 1.71; 21 studies, 1972 participants; low-certainty evidence) and motor function (SMD 0.69, 95% CI 0.46 to 0.92; 22 studies, 1965 participants; low-certainty evidence). Very few studies assessed these outcomes at long-term follow-up. Additional physical rehabilitation may improve balance (MD 5.74, 95% CI 3.78 to 7.71; 15 studies, 795 participants; low-certainty evidence) and gait velocity (SMD 0.59, 95% CI 0.26 to 0.91; 19 studies, 1004 participants; low-certainty evidence). Very few studies assessed these outcomes at long-term follow-up. Is any one approach to physical rehabilitation more effective than any other approach? Compared to other approaches, those that focus on functional task training may improve IADL (SMD 0.58, 95% CI 0.29 to 0.87; 22 studies, 1535 participants; low-certainty evidence) and motor function (SMD 0.72, 95% CI 0.21 to 1.22; 20 studies, 1671 participants; very low-certainty evidence) but the evidence in the latter is very uncertain. The benefit was sustained long-term. The evidence is very uncertain about the effect of functional task training on balance (MD 2.16, 95% CI -0.24 to 4.55) and gait velocity (SMD 0.28, 95% CI -0.01 to 0.56). Compared to other approaches, neurophysiological approaches may be less effective than other approaches in improving IADL (SMD -0.34, 95% CI -0.63 to -0.06; 14 studies, 737 participants; low-certainty evidence), and there may be no difference in improving motor function (SMD -0.60, 95% CI -1.32 to 0.12; 13 studies, 663 participants; low-certainty evidence), balance (MD -0.60, 95% CI -5.90 to 6.03; 9 studies, 292 participants; low-certainty evidence), and gait velocity (SMD -0.17, 95% CI -0.62 to 0.27; 16 studies, 630 participants; very low-certainty evidence), but the evidence is very uncertain about the effect on gait velocity. For all comparisons, the evidence is very uncertain about the effects of physical rehabilitation on adverse events and length of hospital stay.

AUTHORS' CONCLUSIONS

Physical rehabilitation, using a mix of different treatment components, likely improves recovery of function and mobility after stroke. Additional physical rehabilitation, delivered as an adjunct to 'usual' rehabilitation, may provide added benefits. Physical rehabilitation approaches that focus on functional task training may be useful. Neurophysiological approaches to physical rehabilitation may be no different from, or less effective than, other physical rehabilitation approaches. Certainty in this evidence is limited due to substantial heterogeneity, with mainly small studies and important differences between study populations and interventions. We feel it is unlikely that any studies published since November 2022 would alter our conclusions. Given the size of this review, future updates warrant consensus discussion amongst stakeholders to ensure the most relevant questions are explored for optimal decision-making.

Omaha System-Based Extended Nursing Care in Hypertensive Cerebral Hemorrhage: A Randomized Study

BACKGROUND

Traditional nursing care often fails to meet the complex needs of hypertensive cerebral hemorrhage patients. Limited evidence exists on the efficacy of structured nursing frameworks such as the Omaha System in postoperative care for these patients.

OBJECTIVE

This study aims to evaluate the efficacy of Omaha-based extended nursing care in improving patients' outcomes.

METHODS

This randomized controlled trial included 53 patients with hypertensive cerebral hemorrhage admitted to the neurosurgical department of a large tertiary hospital in Chengdu, China, from March to September 2023. Participants were randomly assigned to either the traditional nursing care (n = 26) or the Omaha-based nursing care in addition to the traditional nursing care (n = 27). Outcomes included self-health management abilities, anxiety and depression levels, quality-of-life, and functional independence. Data were collected before nursing care and 1- and 3-months post-nursing care.

RESULTS

Omaha-based nursing care demonstrated improvements in self-health management abilities, with cognition scores increasing from a baseline of 31.65 (4.37) to 57.32 (5.11) at 3-months (mean difference: 25.67, 95%CI [23.45, 27.89], p = .01). Anxiety levels decreased in the Omaha-based nursing group, with SAS scores reducing from 45.71 (3.48) to 28.26 (2.74) at 3-months (mean difference: -17.45, 95% CI [-19.02, -15.88], p < .01). Quality-of-life scores improved in the Omaha-based nursing group, increasing from 6.3 (1.2) to 7.9 (0.9) at 3-months (mean difference: 1.6, 95% CI [1.12, 2.08], p = .03). Functional independence scores were also higher in the Omaha-based nursing group at 3-months (mean difference: 9.2, 95% CI [6.11, 12.29], p = .03).

CONCLUSION

Our findings support the integration of the Omaha System into postoperative care protocols for this patient population. However, further validation is warranted by larger trials.

Effect of early mobilization on the development of pneumonia in patients with traumatic brain injury in the neurosurgical intensive care unit: A historical controls study

BACKGROUND

Pneumonia has a high incidence in traumatic brain injury (TBI) patients and lacks effective treatments. Early mobilization (EM) may be a potentially effective treatment.

AIM

To explore the impact of EM on TBI-related pneumonia in the neurosurgical intensive care unit (NICU).

STUDY DESIGN

This study was a historical control study. 100 TBI patients who received EM intervention were prospectively included as the experimental group (EM cohort), and 250 TBI patients were retrospectively included as the control group. The propensity score matching (PSM) method was employed to balance baseline and minimize potential bias. The relationship between EM and TBI-related pneumonia was investigated by univariate and multivariate logistic regression, then further determined by subgroup analysis. The influence of other variables was excluded by interaction analyses. Finally, the effect of EM on the prognosis of TBI patients was analysed by comparing the Glasgow Coma Scale (GCS) and the hospital stay.

RESULTS

After screening, 86 patients were included in the EM cohort and 199 patients were included in the control cohort. There were obvious differences between the two cohorts at baseline, and these differences were eliminated after PSM, when the incidence of pneumonia was significantly lower in the EM cohort than in the control cohort (35.0% vs. 61.9%, p < .001). Multivariate logistic regression showed that EM was an independent risk factor for TBI-related pneumonia and was significantly associated with a decreased incidence of pneumonia. This correlation was present in most subgroups and was not affected by other variables (p for interaction >.05). Patients in the EM cohort had shorter length of ICU stay (6 vs. 7 days, p = .017) and higher GCS at discharge (12 vs. 11, p = .010).

CONCLUSION

EM is a safe and effective treatment for TBI patients in NICU, which can reduce the incidence of pneumonia, help to improve prognosis and shorten the length of ICU stay.

RELEVANCE TO CLINICAL PRACTICE

Although the utilization rate of EM is low in TBI patients for various reasons, EM is still an effective method to prevent complications. Our study confirms that a scientific and detailed EM strategy can effectively reduce the incidence of pneumonia while ensuring the safety of TBI patients, which is worthy of further research and clinical application.

Effects of motor imagery-based brain-computer interface-controlled electrical stimulation on lower limb function in hemiplegic patients in the acute phase of stroke: a randomized controlled study

Background

Lower limb motor dysfunction is one of the most serious consequences of stroke; however, there is insufficient evidence for optimal rehabilitation strategies. Improving lower limb motor function through effective rehabilitation strategies is a top priority for stroke patients. Neuroplasticity is a key factor in the recovery of motor function. The extent to which neuroplasticity-based rehabilitation therapy using brain-computer interface (BCI) is effective in treating lower limb motor dysfunction in acute ischemic stroke patients has not been extensively investigated.

Objective

This study aimed to assess the impact of BCI rehabilitation on lower limb motor dysfunction in individuals with acute ischemic stroke by evaluating motor function, walking ability, and daily living activities.

Methods

This study was conducted in a randomized controlled trial, involving 64 patients with acute ischemic stroke who experienced lower limb motor dysfunction. All patients were divided into two groups, with 32 patients assigned to the control group was given conventional rehabilitation once a day for 70 min, 5 times a week for 2 weeks, and the experimental group (n = 32) was given BCI rehabilitation on top of the conventional rehabilitation for 1 h a day, 30 min of therapy in the morning and an additional 30 min in the afternoon, for a total of 20 sessions over a two-week period. The primary outcome was lower extremity motor function, which was assessed using the lower extremity portion of the Fugl-Meyer Rating Scale (FMA-LE), and the secondary endpoints were the Functional Ambulation Scale (FAC), and the Modified Barthel index (MBI).

Results

After 20 sessions of treatment, both groups improved in motor function, walking function, and activities of daily living, and the improvements in FMA-LE scores (p < 0.001), FAC (p = 0.031), and MBI (p < 0.001) were more pronounced in the experimental group compared with the control group.

Conclusion

Conventional rehabilitation therapy combined with BCI rehabilitation therapy can improve the lower limb motor function of hemiplegic patients with stroke, enhance the patient's ability to perform activities of daily living, and promote the improvement of walking function, this is an effective rehabilitation policy to promote recovery from lower extremity motor function disorders.

Intracranial Hemorrhage-Is Very Early Rehabilitation Safe? A Narrative Review

Intracerebral hemorrhage (ICH) is a serious neurological disease with a 30-day mortality rate of 34-50%. Rehabilitation can reduce disability and improve recovery from a stroke; however, it is uncertain whether early rehabilitation is safe. There are many studies and reviews on rehabilitation for chronic conditions, but there is not enough information on the details of rehabilitation in the acute and subacute phases of ICH. We analyzed clinical trials from the electronic databases PubMed, PubMedCentral, Medline, Cochrane Library, Embase, Scopus and PEDro. Based on the data, we determined that early rehabilitation of patients with ICH has beneficial effects on improving ADL scores, motor function, functional independence, quality of life, improved gait, improved trunk control and reduced mortality. Varying the duration and intensity of rehabilitation in patients with ICH may improve health status, functional outcomes and reduce the length of stay in the hospital. The earliest protocol for initiating rehabilitation after ICH included up to 24 h after stroke onset. The medical literature indicates the need for more randomized controlled group trials of early rehabilitation in patients with acute and subacute ICH with a precise timing of rehabilitation initiation. This narrative review aims to summarize the existing evidence and provide insights into the current state of knowledge regarding the safety of early rehabilitation. There is a need for a clear definition of "early rehabilitation" when determining the most appropriate time to begin rehabilitation therapy.

Assessing the impact of early progressive mobilization on moderate-to-severe traumatic brain injury: a randomized controlled trial

INTRODUCTION

Traumatic brain injury (TBI) is a major cause of neurodisability worldwide, with notably high disability rates among moderately severe TBI cases. Extensive previous research emphasizes the critical need for early initiation of rehabilitation interventions for these cases. However, the optimal timing and methodology of early mobilization in TBI remain to be conclusively determined. Therefore, we explored the impact of early progressive mobilization (EPM) protocols on the functional outcomes of ICU-admitted patients with moderate to severe TBI.

METHODS

This randomized controlled trial was conducted at a trauma ICU of a medical center; 65 patients were randomly assigned to either the EPM group or the early progressive upright positioning (EPUP) group. The EPM group received early out-of-bed mobilization therapy within seven days after injury, while the EPUP group underwent early in-bed upright position rehabilitation. The primary outcome was the Perme ICU Mobility Score and secondary outcomes included Functional Independence Measure motor domain (FIM-motor) score, phase angle (PhA), skeletal muscle index (SMI), the length of stay in the intensive care unit (ICU), and duration of ventilation.

RESULTS

Among 65 randomized patients, 33 were assigned to EPM and 32 to EPUP group. The EPM group significantly outperformed the EPUP group in the Perme ICU Mobility and FIM-motor scores, with a notably shorter ICU stay by 5.9 days (p < 0.001) and ventilation duration by 6.7 days (p = 0.001). However, no significant differences were observed in PhAs.

CONCLUSION

The early progressive out-of-bed mobilization protocol can enhance mobility and functional outcomes and shorten ICU stay and ventilation duration of patients with moderate-to-severe TBI. Our study's results support further investigation of EPM through larger, randomized clinical trials. Clinical trial registration ClinicalTrials.gov NCT04810273 . Registered 13 March 2021.

Impact of Early Mobilization on Patients With Acute Ischemic Stroke Treated With Thrombolysis or Thrombectomy: A Randomized Controlled Trial

BACKGROUND

Early mobilization (EM) within 24 to 72 hours post-stroke may improve patients' performance and ability. However, after intravenous thrombolysis (IVT) or mechanical thrombectomy (MT), the increased risk of hemorrhagic complications impacts the implementation of early out-of-bed mobilization. Few studies have investigated EM after IVT or MT for acute ischemic stroke (AIS), and its impact in these patients is unknown.

OBJECTIVE

To investigate the effect of EM on AIS treated with IVT or MT.|.

METHODS

We recruited 122 patients with first AIS; 60 patients were treated with IVT, and 62 patients were treated with MT. For each IVT and MT cohort, the control groups received standard early rehabilitation, and the intervention groups received an EM protocol. The training lasted 30 minutes/day, 5 days/week until discharge.

MAIN OUTCOMES MEASURES

The effectiveness of the interventions was evaluated using the motor domain of the Functional Independence Measure (FIM-motor) and the Postural Assessment Scale for Stroke Patients (PASS) at baseline, 2-week, 4-week, and 3-month post-stroke, the Functional Ambulation Category 2-week post-stroke, and the total length of stay at the stroke center.

RESULTS

Both IVT and MT treatment groups showed improved FIM-motor and PASS scores over time; however, only the IVT EM group had significantly improved FIM-motor performance within 1 month after stroke than the control group. Conclusion. An EM protocol with the same intervention time and session frequency per day as in the standard care protocol was effective in improving the functional ability of stroke patients after IVT.

Exploring the status and associated factors of the readiness for return-to-work in young and middle-aged stroke patients

Stroke increasingly affects individuals of working age. An accurate assessment of Readiness for Return-to-Work (RRTW) can help determine the optimal timing for RRTW and facilitate an early reintegration into society. This study investigates the current state of RRTW and the influencing factors among young and middle-aged stroke patients in China. A sample of young and middle-aged stroke patients hospitalized in a tertiary hospital in Henan Province between December 2021 and May 2022 were included in this study. A general information questionnaire and the Readiness for RRTW scale, the Social Support Rate Scale, the Stroke Self-Efficacy Scale, and the Fatigue Severity Scale were administered to the patients. Of the 203 patients successfully surveyed, 60 (29.6%) were in the pre-contemplation stage, 35 (17.2%) in the contemplation stage, 81 (39.9%) in the prepared for action-self-evaluative stage, and 27 (13.3%) in the prepared for action- behavior stage. Logistic regression analysis identified education level, monthly income, time to start rehabilitation therapy, social support, stroke self-efficacy, and fatigue severity as key factors affecting RRTW scale readiness in young and middle-aged stroke patients. The readiness of young and middle-aged stroke patients to Return-to-Work needs to be increased further. Healthcare professionals should consider the influencing factors of RRTW and design targeted intervention programs to facilitate a successful Return-to-Work and normal life.

Variation in the rate of recovery in motor function between the upper and lower limbs in patients with stroke: some proposed hypotheses and their implications for research and practice

Background

Stroke results in impairment of motor function of both the upper and lower limbs. However, although it is debatable, motor function of the lower limb is believed to recover faster than that of the upper limb. The aim of this paper is to propose some hypotheses to explain the reasons for that, and discuss their implications for research and practice.

Method

We searched PubMED, Web of Science, Scopus, Embase and CENTRAL using the key words, stroke, cerebrovascular accident, upper extremity, lower extremity, and motor recovery for relevant literature.

Result

The search generated a total of 2,551 hits. However, out of this number, 51 duplicates were removed. Following review of the relevant literature, we proposed four hypotheses: natural instinct for walking hypothesis, bipedal locomotion hypothesis, central pattern generators (CPGs) hypothesis and role of spasticity hypothesis on the subject matter.

Conclusion

We opine that, what may eventually account for the difference, is the frequency of use of the affected limb or intensity of the rehabilitation intervention. This is because, from the above hypotheses, the lower limb seems to be used more frequently. When limbs are used frequently, this will result in use-dependent plasticity and eventual recovery. Thus, rehabilitation techniques that involve high repetitive tasks practice such as robotic rehabilitation, Wii gaming and constraint induced movement therapy should be used during upper limb rehabilitation.

Huge variability in restrictions of mobilization for patients with aneurysmal subarachnoid hemorrhage - A European survey of practice

Introduction

One of the major goals of neurointensive care is to prevent secondary injuries following aSAH. Bed rest and patient immobilization are practiced in order to decrease the risk of DCI.

Research question

To explore the current practices in place concerning the management of patients with aSAH, specifically, protocols and habits regarding restrictions of mobilization and HOB positioning.

Material and methods

A survey was designed, modified, and approved by the panel of the Trauma & Critical Care section of the EANS to cover the practice of restrictions of patient mobilization and HOB positioning in patients with aSAH.

Results

Twenty-nine physicians from 17 countries completed the questionnaire. The majority (79.3%) stated that non-secured aneurysm and the presence of an EVD were the factors related to the establishment of restriction of mobilization. The average duration of the restriction varied widely ranging between 1 and 21 days. The presence of an EVD (13.8%) was found to be the main reason to recommend restriction of HOB elevation. The average duration of restriction of HOB positioning ranged between 3 and 14 days. Rebleeding or complications related to CSF over-drainage were found to be related to these restrictions.

Discussion and conclusion

Restriction of patient mobilization regimens vary widely in Europe. Current limited evidence does not support an increased risk of DCI rather the early mobilization might be beneficial. Large prospective studies and/or the initiative of a RCT are needed to understand the significance of early mobilization on the outcome of patients with aSAH.

Functional mobility effects of progressive early mobilization protocol on people with moderate-to-severe traumatic brain injury: A pre-post intervention study

BACKGROUND: Brain plasticity evoked by environmental enrichment through early mobilization may improve sensorimotor functions of patients with moderate-to-severe traumatic brain injury (TBI). Increasing evidence also suggests that early mobilization increases verticalization, which is beneficial to TBI patients in critical care. However, there are limited data on early mobilization interventions provided to patients with moderate-to-severe TBI. OBJECTIVE: We investigated the possible enhancing effects of revised progressive early mobilization on functional mobility and the rate of out-of-bed mobility attained by patients with moderate-to-severe TBI. METHODS: This is a quantitative study with a retrospective and prospective pre–post intervention design. We implemented a revised progressive early mobilization protocol for patients with moderate-to-severe TBI admitted to the trauma intensive care unit (ICU) within the previous seven days. The outcome parameters were the rate of patients attaining early mobilization (sitting on the edge of the bed) and the Perme ICU Mobility Score at discharge from the ICU. The outcome parameters in the intervention cohort were compared with those from a historical control cohort who received standard medical care a year previously. Differences in the Perme ICU Mobility Score between the two cohorts were assessed using univariate analysis of covariance. RESULTS: Forty-two patients were included in the progressive early mobilization program and were compared with 44 patients who underwent standard medical care. In the intervention cohort, 100% and 57.2% of the patients completed early rehabilitation and early mobilization, respectively, compared to 0% in the control cohort. The intervention cohort at ICU discharge showed significantly improved the Perme ICU Mobility Scores. CONCLUSIONS: The implementation of the revised progressive early mobilization program for patients with moderate-to-severe TBI resulted in significantly improved mobility at ICU discharge; however, the length of overall stay in the ICU may be not affected.

Inhibitors of early mobilization in the acute phase of intracerebral hemorrhage: A retrospective observational study

OBJECTIVES

The association between early mobilization and functional prognosis in the acute phase of intracerebral hemorrhage has been reported, but only a few studies have investigated the inhibitors of early mobilization in the acute phase of intracerebral hemorrhage. This study aimed to investigate the inhibitors of early mobilization.

MATERIALS AND METHODS

The study enrolled 322 patients with intracerebral hemorrhage. In the early mobilization group, mobilization was started within 72 h from onset, and in the delayed mobilization group, mobilization was started at or after 72 h from onset. The association between the start of mobilization timing and baseline characteristics was investigated using univariate and multivariate analyses to clarify the inhibitors of early mobilization in the acute phase of intracerebral hemorrhage.

RESULTS

Significant differences between the early mobilization and delayed mobilization groups were observed in the lesion site, leukocyte count at admission, neutrophil count at admission, C-reactive protein level at admission, surgery, use of mechanical ventilation, consciousness level at admission, hematoma volume, and hematoma growth. In the multiple logistic regression analysis, five items were adopted, namely, low consciousness level at admission, lesion below the tent, surgery, C-reactive protein at admission, and hematoma growth.

CONCLUSIONS

In this study, low consciousness level at admission, lesion below the tent, surgery, C-reactive protein level at admission, and hematoma growth affected delayed mobilization. Therefore, it is recommended to judge the start of mobilization timing by a systematic evidenced-based assessment for each case.

Safety and Efficacy of Early Rehabilitation After Stroke Using Mechanical Thrombectomy: A Pilot Randomized Controlled Trial

Background

Early rehabilitation (ER) has been reported to be both safe and feasible for patients' post-stroke. To date, however, ER-related outcomes concerning patients who have undergone mechanical thrombectomy (MT) have not been investigated. This study aimed to determine the feasibility of ER and whether it improves prognosis in such patients.

Methods

In this single-center, double-blinded, randomized controlled study involving 103 patients who met the study criteria (i.e., has undergone MT), we randomly divided patients (1:1) into ER and conventional rehabilitation groups. The primary outcome was mortality, while secondary outcomes included favorable outcomes (modified Rankin scale of 0–2), the incidence of non-fatal complications, and Barthel Index (BI) scores. We assessed outcomes at 3 months and 1-year post-stroke.

Results

No significant between-group differences were found in terms of mortality and favorable outcomes at 3 months and 1-year post-stroke. At 3 months, 15 (28.8%) patients in the ER group and 29 (56.9%) in the conventional rehabilitation group (p = 0.002) had non-fatal complications. The BI in the ER and conventional rehabilitation groups was 100 (85–100) and 87.5 (60–100), respectively, (p = 0.007). At 1 year, the incidence of non-fatal complications was similar between both groups [BI in the ER group, 100 (90–100), p = 0.235; BI in the conventional rehabilitation group, 90 (63.8–100); p = 0.003].

Conclusion

Early rehabilitation (ER) reduces the incidence of early immobility-related complications and effectively improves patients' activities of daily living on a short- and long-term basis. Our results indicate that MT contributes to ER in patients with stroke.

Clinical Trial Registration

www.chictr.org.cn, identifier: ChiCTR1900022665.

Factors Associated With Physical Therapy Engagement During the Period of Posttraumatic Amnesia

BACKGROUND AND PURPOSE

Physical therapy is important in the management of traumatic brain injury (TBI) and associated multitrauma. Providing therapy during the posttraumatic amnesia (PTA) phase is challenging, given that hallmark features including confusion, amnesia, agitation, and fatigue may impede the person's ability to engage in and benefit from rehabilitation. To date, there is little empirical evidence to guide the provision of therapy during PTA. This observational study aimed to explore the frequency, duration, location, and engagement of physical therapy provision during PTA and the impact of cognition, agitation, and fatigue.

SUMMARY OF KEY POINTS

The majority of patients were found to meaningfully engage and participate in physical therapy for the majority of sessions. Only a small proportion were unable to participate in physical therapy. Patient refusal and fatigue were identified as the most prominent barriers to rehabilitation. Despite fatigue and agitation reaching clinical levels, therapy could still successfully proceed on most occasions.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Physical therapy is feasible during the acute recovery stages after TBI. Current results support the notion that therapy should commence early to minimize secondary complications and promote the recovery of mobility. A patient-centered therapeutic model that tailors the therapeutic approach to meet the individual's current physical and fluctuating cognitive capabilities may be most suited for this population. Clinicians working with people after TBI need experience in understanding and managing the cognitive limitations and associated symptoms of PTA to optimize the provision of therapy. These findings could inform guidelines for the management of patients in PTA.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A368).

Central Nervous System Tissue Regeneration after Intracerebral Hemorrhage: The Next Frontier

Despite marked advances in surgical techniques and understanding of secondary brain injury mechanisms, the prognosis of intracerebral hemorrhage (ICH) remains devastating. Harnessing and promoting the regenerative potential of the central nervous system may improve the outcomes of patients with hemorrhagic stroke, but approaches are still in their infancy. In this review, we discuss the regenerative phenomena occurring in animal models and human ICH, provide results related to cellular and molecular mechanisms of the repair process including by microglia, and review potential methods to promote tissue regeneration in ICH. We aim to stimulate research involving tissue restoration after ICH.

Interventions for reducing sedentary behaviour in people with stroke

BACKGROUND

Stroke survivors are often physically inactive as well as sedentary,and may sit for long periods of time each day. This increases cardiometabolic risk and has impacts on physical and other functions. Interventions to reduce or interrupt periods of sedentary time, as well as to increase physical activity after stroke, could reduce the risk of secondary cardiovascular events and mortality during life after stroke.

OBJECTIVES

To determine whether interventions designed to reduce sedentary behaviour after stroke, or interventions with the potential to do so, can reduce the risk of death or secondary vascular events, modify cardiovascular risk, and reduce sedentary behaviour.

SEARCH METHODS

In December 2019, we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, Conference Proceedings Citation Index, and PEDro. We also searched registers of ongoing trials, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing interventions to reduce sedentary time with usual care, no intervention, or waiting-list control, attention control, sham intervention or adjunct intervention. We also included interventions intended to fragment or interrupt periods of sedentary behaviour.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies and performed 'Risk of bias' assessments. We analyzed data using random-effects meta-analyses and assessed the certainty of the evidence with the GRADE approach.

MAIN RESULTS

We included 10 studies with 753 people with stroke. Five studies used physical activity interventions, four studies used a multicomponent lifestyle intervention, and one study used an intervention to reduce and interrupt sedentary behaviour. In all studies, the risk of bias was high or unclear in two or more domains. Nine studies had high risk of bias in at least one domain. The interventions did not increase or reduce deaths (risk difference (RD) 0.00, 95% confidence interval (CI) -0.02 to 0.03; 10 studies, 753 participants; low-certainty evidence), the incidence of recurrent cardiovascular or cerebrovascular events (RD -0.01, 95% CI -0.04 to 0.01; 10 studies, 753 participants; low-certainty evidence), the incidence of falls (and injuries) (RD 0.00, 95% CI -0.02 to 0.02; 10 studies, 753 participants; low-certainty evidence), or incidence of other adverse events (moderate-certainty evidence). Interventions did not increase or reduce the amount of sedentary behaviour time (mean difference (MD) +0.13 hours/day, 95% CI -0.42 to 0.68; 7 studies, 300 participants; very low-certainty evidence). There were too few data to examine effects on patterns of sedentary behaviour. The effect of interventions on cardiometabolic risk factors allowed very limited meta-analysis.

AUTHORS' CONCLUSIONS

Sedentary behaviour research in stroke seems important, yet the evidence is currently incomplete, and we found no evidence for beneficial effects. Current World Health Organization (WHO) guidelines recommend reducing the amount of sedentary time in people with disabilities, in general. The evidence is currently not strong enough to guide practice on how best to reduce sedentariness specifically in people with stroke. More high-quality randomised trials are needed, particularly involving participants with mobility limitations. Trials should include longer-term interventions specifically targeted at reducing time spent sedentary, risk factor outcomes, objective measures of sedentary behaviour (and physical activity), and long-term follow-up.

Effectiveness of Whole-Body Vibration Training to Improve Muscle Strength and Physical Performance in Older Adults: Prospective, Single-Blinded, Randomized Controlled Trial

Whole-body vibration training (WBVT) is emerging as an alternative exercise method that be easily performed by older adults. This clinical trial investigates the efficacy of WBVT in improving muscle strength and physical performance before resistance exercise, in comparison to conventional resistance exercise after stretching exercise in older adults. The WBVT group (n = 20) performed WBVT using a vibrating platform (SW-VC15™), followed by strengthening exercises. The control group (n = 20) performed stretching instead of WBVT. Both groups underwent a total of 12 sessions (50 min per session). The primary outcome was isokinetic dynamometer. The secondary outcomes were grip strength, short physical performance battery (SPPB), a 36-Item Short Form Survey (SF-36), and body composition analysis. In all results, only the time effect was significant, and the group effect or time x group effect was not. Both groups showed a significant increase in isokinetic dynamometer. Although there was no significant group effect, the increase in mean peak torque was greater in the WBVT group. The only WBVT group showed significant improvement in SPPB. In SF-36, only the control group showed significant improvements. WBVT can be safely performed by older adults and may be an alternative exercise method to boost the effect of strengthening exercise.

Effects of early mobilization on short-term blood pressure variability in acute intracerebral hemorrhage patients: A protocol for randomized controlled non-inferiority trial

BACKGROUND

Early out-of-bed mobilization may improve acute post-intracerebral hemorrhage (ICH) outcomes, but hemodynamic instability may be a concern. Some recent studies have showed that an increase in mean systolic blood pressure (SBP) and high blood pressure variability (BPV), high standard deviation of SBP, may lead to negative ICH outcomes. Therefore, we investigated the impact of an early mobilization (EM) protocol on mean SBP and BPV during the acute phase.

METHODS

The study was an assessor-blinded, randomized controlled non-inferiority study. The participants were in An Early Mobilization for Acute Cerebral Hemorrhage trial and were randomly assigned to undergo EM or a standard early rehabilitation (SER) protocol within 24 to 72 hour after ICH onset at the stroke center. The EM and SER groups each had 30 patients. 24-measurement SBP were recorded on days 2 and 3 after onset, and SBP were recorded three times daily and during rehabilitation on days 4 through 7. The two groups' mean SBP and BPV under three different time frames (days 2 and 3 during the acute phase, and days 4 through 7 during the late acute phase) were calculated and compared.

RESULTS

At baseline, the two groups' results were similar, with the exception being that the mean time to first out-of-bed mobilization after symptom onset was 51.60 hours (SD 14.15) and 135.02 hours (SD 33.05) for the EM group and SER group, respectively (P < .001). There were no significant differences in mean SBP and BPV during the acute and late acute phase between the two groups for the three analyses (days 2, 3, and 4 through 7) (P > .05).

CONCLUSIONS

It is safe to implement the EM protocol within 24 to 72 hour of onset for mild-moderate ICH patients during the acute phase.

Time Window for Ischemic Stroke First Mobilization Effectiveness: Protocol for an Investigator-Initiated Prospective Multicenter Randomized 3-Arm Clinical Trial

OBJECTIVE

The purpose of this study is to investigate the optimal time window for initiating mobilizing after acute ischemic stroke.

METHODS

The TIME Trial is a pragmatic, investigator-initiated, multi-center, randomized, 3-arm parallel group, clinical trial. This trial will be conducted in 57 general hospitals in mainland China affiliated with the China Stroke Databank Center and will enroll 6033 eligible patients with acute ischemic stroke. Participants will be randomly allocated to either (1) the very early mobilization group in which mobilization is initiated within 24 hours from stroke onset, (2) the early mobilization group in which mobilization begins between 24 and 72 hours poststroke, or (3) the late mobilization group in which mobilization is started after 72 hours poststroke. The mobilization protocol is otherwise standardized and identical for each comparison group. Mobilization is titrated by baseline mobility level and progress of patients throughout the intervention period. The primary outcome is death or disability assessed with the modified Rankin scale at 3 months poststroke. Secondary outcomes include impairment score of the National Institutes of Health Stroke Scale, dependence in activities of daily living as measured using the modified Barthel Index, cognitive ability assessed with the Mini-Mental State Examination, incidence of adverse events, hospital length of stay, and total medical costs.

IMPACT

The TIME Trial is designed to answer the question "when is the best time to start mobilization after stroke?" The effect of timing is isolated from the effect of type and dose of mobilization by otherwise applying a standard mobilization protocol across groups. The TIME Trial may, therefore, contribute to increasing the knowledge base regarding the optimal time window for initiating mobilization after acute ischemic stroke.

Review: How Can Intelligent Robots and Smart Mechatronic Modules Facilitate Remote Assessment, Assistance, and Rehabilitation for Isolated Adults With Neuro-Musculoskeletal Conditions?

Worldwide, at the time this article was written, there are over 127 million cases of patients with a confirmed link to COVID-19 and about 2.78 million deaths reported. With limited access to vaccine or strong antiviral treatment for the novel coronavirus, actions in terms of prevention and containment of the virus transmission rely mostly on social distancing among susceptible and high-risk populations. Aside from the direct challenges posed by the novel coronavirus pandemic, there are serious and growing secondary consequences caused by the physical distancing and isolation guidelines, among vulnerable populations. Moreover, the healthcare system's resources and capacity have been focused on addressing the COVID-19 pandemic, causing less urgent care, such as physical neurorehabilitation and assessment, to be paused, canceled, or delayed. Overall, this has left elderly adults, in particular those with neuromusculoskeletal (NMSK) conditions, without the required service support. However, in many cases, such as stroke, the available time window of recovery through rehabilitation is limited since neural plasticity decays quickly with time. Given that future waves of the outbreak are expected in the coming months worldwide, it is important to discuss the possibility of using available technologies to address this issue, as societies have a duty to protect the most vulnerable populations. In this perspective review article, we argue that intelligent robotics and wearable technologies can help with remote delivery of assessment, assistance, and rehabilitation services while physical distancing and isolation measures are in place to curtail the spread of the virus. By supporting patients and medical professionals during this pandemic, robots, and smart digital mechatronic systems can reduce the non-COVID-19 burden on healthcare systems. Digital health and cloud telehealth solutions that can complement remote delivery of assessment and physical rehabilitation services will be the subject of discussion in this article due to their potential in enabling more effective and safer NMSDK rehabilitation, assistance, and assessment service delivery. This article will hopefully lead to an interdisciplinary dialogue between the medical and engineering sectors, stake holders, and policy makers for a better delivery of care for those with NMSK conditions during a global health crisis including future pandemics.

Compensation of Ipsilateral Motor and Sensory Functions by Contralateral Uncrossed Pathway in a Stroke Patient With Half Brain

ABSTRACT

This study reports a case of motor and sensory function recovery after massive left cerebral infarction in a young man, along with preserved function of the injured hemisphere. He received early rehabilitation therapy in a nerval care unit within 1 wk of surgery, and the rehabilitation lasted for more than 3 yrs. When he gradually recovered from coma, his motor, sensory, and speech functions improved significantly. Two years later, he was able to live independently and returned to work. The findings of functional magnetic resonance imaging, diffusion tensor imaging, somatosensory evoked potential, and motor evoked potential confirmed that there was a strong connection between his right brain and the right limbs. Thus, early rehabilitation is a promising approach for restoring motor and sensory function after massive brain injury or extensive brain tissue damage.

Early physical rehabilitation vs standard care for intracerebral hemorrhage stroke: A protocol for systematic review and meta-analysis

BACKGROUND

The intracerebral hemorrhagic stroke (ICH) is associated with high mortality and severe disability in survivors, which causing about 42% of the disability-adjusted life years lost and 50% of all stroke patients dead within 1 year. Although early functional training is recommended to facility rehabilitation after the stroke, the benefit and safety are still controversial.

INTRODUCTION

This systematic review aims to investigate whether early physical rehabilitation could have a beneficial effect for the patients with ICH compared with standard rehabilitation care.

METHODS AND ANALYSIS

Pubmed, Embase, and Cochrane library will be searched to include randomized control trials which investigate the rehabilitation effective of the early mobilization for patients with ICH compared with routine nursing or standard care. Rev-Man version 5.3 will be used to perform all calculations related to the meta-analysis. Dichotomous data will be calculated in terms of a fixed or random effect model and expressed by the relative risk (RR) with 95% confidence interval (CI). The Cochrane collaborations tool in the following aspects was used to assess the risk of bias (ROB) in included studies. The inconsistency index (I2) and Chi-Squared will be applied for heterogeneity detection between clinical trials. A value of P < .05 will be considered statistically significant.

CONCLUSION

This study will explore the role of early physical rehabilitation and provide insight for clinicals to improve rehabilitation results of ICH.

REGISTRATION NUMBER

INPLASY2020110068.