Nonpharmacological Treatments for Hospitalized Patients with Stroke: A Nuanced Approach to Prescribing Early Activity.

Stroke remains a leading cause of adult disability. To date, hyperacute revascularization procedures reach 5-10% of stroke patients even in high resource health systems. There is a limited time window for brain repair after stroke, and therefore, the activities such as prescribed exercise in the earliest period will likely have long-term significant consequences. Clinicians who provide care for hospitalized stroke patients make treatment decisions specific to activity often without guidelines to direct these prescriptions. This requires a balanced understanding of the available evidence for early post-stroke exercise and physiological principles after stroke that drive the safety of prescribed exercise. Here, we provide a summary of these relevant concepts, identify gaps, and recommend an approach to prescribing safe and meaningful activity for all patients with stroke. The population of thrombectomy-eligible stroke patients can be used as the exemplar for conceptualization.

Development and Implementation of a Standard Assessment Battery Across the Continuum of Care for Patients After Stroke.

ABSTRACT: Stroke rehabilitation occurs across the continuum of care starting in the acute hospital and through the inpatient and outpatient settings. Rehabilitation aims to minimize impairments and maximize function in individuals after stroke. Because patients often undergo rehabilitation for extended periods, longitudinal assessment of impairment, activity, and participation can facilitate the evaluation of patients' progress toward recovery, as well as communication and decision making to guide clinical practice regarding the intervention(s) to be used and may also be leveraged for clinical research. However, the clinical implementation of a standard assessment battery that spans the continuum of care for patients after stroke is challenging because of operational and time constraints. Here, we describe the development and implementation of a standard assessment battery across the continuum of care by physical therapists, occupational therapists, and speech-language pathologists at the Sheikh Khalifa Stroke Institute. We specifically describe our experience in (1) identifying the core team to lead the process, (2) selecting the measures for the standard assessment battery, and the timeframe for administration, and (3) implementing the standard assessment battery in routine clinical practice.

Comparing a Novel Neuroanimation Experience to Conventional Therapy for High-Dose Intensive Upper-Limb Training in Subacute Stroke: The SMARTS2 Randomized Trial.

BACKGROUND: Evidence from animal studies suggests that greater reductions in poststroke motor impairment can be attained with significantly higher doses and intensities of therapy focused on movement quality. These studies also indicate a dose-timing interaction, with more pronounced effects if high-intensity therapy is delivered in the acute/subacute, rather than chronic, poststroke period. OBJECTIVE: To compare 2 approaches of delivering high-intensity, high-dose upper-limb therapy in patients with subacute stroke: a novel exploratory neuroanimation therapy (NAT) and modified conventional occupational therapy (COT). METHODS: A total of 24 patients were randomized to NAT or COT and underwent 30 sessions of 60 minutes time-on-task in addition to standard care. The primary outcome was the Fugl-Meyer Upper Extremity motor score (FM-UE). Secondary outcomes included Action Research Arm Test (ARAT), grip strength, Stroke Impact Scale hand domain, and upper-limb kinematics. Outcomes were assessed at baseline, and days 3, 90, and 180 posttraining. Both groups were compared to a matched historical cohort (HC), which received only 30 minutes of upper-limb therapy per day. RESULTS: There were no significant between-group differences in FM-UE change or any of the secondary outcomes at any timepoint. Both high-dose groups showed greater recovery on the ARAT (7.3 ± 2.9 points; P = .011) but not the FM-UE (1.4 ± 2.6 points; P = .564) when compared with the HC. CONCLUSIONS: Neuroanimation may offer a new, enjoyable, efficient, and scalable way to deliver high-dose and intensive upper-limb therapy.

Safety and Feasibility of a Neuroscience Critical Care Program to Mobilize Patients With Primary Intracerebral Hemorrhage.

OBJECTIVE: To measure the impact of a progressive mobility program on patients admitted to a neurocritical critical care unit (NCCU) with intracerebral hemorrhage (ICH). The early mobilization of critically ill patients with spontaneous ICH is a challenge owing to the potential for neurologic deterioration and hemodynamic lability in the acute phase of injury. Patients admitted to the intensive care unit have been excluded from randomized trials of early mobilization after stroke. DESIGN: An interdisciplinary working group developed a formalized NCCU Mobility Algorithm that allocates patients to incremental passive or active mobilization pathways on the basis of level of consciousness and motor function. In a quasi-experimental consecutive group comparison, patients with ICH admitted to the NCCU were analyzed in two 6-month epochs, before and after rollout of the algorithm. Mobilization and safety endpoints were compared between epochs. SETTING: NCCU in an urban, academic hospital. PARTICIPANTS: Adult patients admitted to the NCCU with primary intracerebral hemorrhage. INTERVENTION: Progressive mobilization after stroke using a formalized mobility algorithm. MAIN OUTCOME MEASURES: Time to first mobilization. RESULTS: The 2 groups of patients with ICH (pre-algorithm rolllout, n=28; post-algorithm rollout, n=29) were similar on baseline characteristics. Patients in the postintervention group were significantly more likely to undergo mobilization within the first 7 days after admission (odds ratio 8.7, 95% confidence interval 2.1, 36.6; P=.003). No neurologic deterioration, hypotension, falls, or line dislodgments were reported in association with mobilization. A nonsignificant difference in mortality was noted before and after rollout of the algorithm (4% vs 24%, respectively, P=.12). CONCLUSIONS: The implementation of a progressive mobility algorithm was safe and associated with a higher likelihood of mobilization in the first week after spontaneous ICH. Research is needed to investigate methods and the timing for the first mobilization in critically ill stroke patients.

Feasibility of Early, Motor-Assisted Cycle Ergometry in Critically Ill Neurological Patients With Upper Limb Weakness and Variable Cognitive Status: A Case Series.

Upper limb paresis, common in many neurological conditions, is a major contributor of long-term disability and decreased quality of life. Evidence shows that repetitive, bilateral arm movement improves upper limb coordination after neurological injury. However, it is difficult to integrate upper limb interventions into very early rehabilitation of critically ill neurological patients because of patient arousal and medical acuity. This report describes the safety and feasibility of bilateral upper limb cycling in critically ill neurological patients with bilateral or unilateral paresis. Patients were included in this pilot observational series if they used upper limb cycle ergometry with occupational therapy while in the neurocritical care unit between May and August 2016. Patient demographics, neurological function, and hemodynamic status were recorded precycling and postcycling. Cycling parameters including duration and active and/or passive cycling were collected. No significant changes in hemodynamic or respiratory status were noted postintervention. No adverse effects or safety events were noted. In this series, upper limb cycle ergometry was a safe and feasible intervention for early rehabilitation in critically ill patients in the neurocritical care unit. Future studies will prospectively measure the impact of early upper limb cycle ergometry on neurological recovery and functional outcome in this population.

Physiological Effects of Early Incremental Mobilization of a Patient with Acute Intracerebral and Intraventricular Hemorrhage Requiring Dual External Ventricular Drainage.

BACKGROUND: Recent trials have challenged the notion that very early mobility benefits patients with acute stroke. It is unclear how cerebral autoregulatory impairments, prevalent in this population, could be affected by mobilization. The safety of mobilizing patients who have external ventricular drainage (EVD) devices for cerebrospinal fluid diversion and intracranial pressure (ICP) monitoring is another concern due to risk of device dislodgment and potential elevation in ICP. We report hemodynamic and ICP responses during progressive, device-assisted mobility interventions performed in a critically ill patient with intracerebral hemorrhage (ICH) requiring two EVDs. METHODS: A 55-year-old man was admitted to the Neuroscience Critical Care Unit with an acute thalamic ICH and complex intraventricular hemorrhage requiring placement of two EVDs. Progressive mobilization was achieved using mobility technology devices. Range of motion exercises were performed initially, progressing to supine cycle ergometry followed by incremental verticalization using a tilt table. Physiological parameters were recorded before and after the interventions. RESULTS: All mobility interventions were completed without any adverse event or clinically detectable change in the patient's neurological state. Physiological parameters including hemodynamic variables and ICP remained within prescribed goals throughout. CONCLUSION: Progressive, device-assisted early mobilization was feasible and safe in this critically ill patient with hemorrhagic stroke when titrated by an interdisciplinary team of skilled healthcare professionals. Studies are needed to gain insight into the hemodynamic and neurophysiological responses associated with early mobility in acute stroke to identify subsets of patients who are most likely to benefit from this intervention.