Comparison of orthostatic reactions of patients still unconscious within the first three months of brain injury on a tilt table with and without integrated stepping. A prospective, randomized crossover pilot trial

Acute orthostatic responses during early mobilisation of patients with acquired brain injury - Innowalk pro versus standing frame

Introduction

Early mobilisation is paramount in the rehabilitation of patients with acquired brain injuries. However, the effectiveness of mobilisation to standing combined with passive leg movement in mitigating orthostatic intolerance remains uncertain. Hence, we investigated whether participants exhibited better tolerance standing in a motorized standing device with passive leg movements, Innowalk Pro, compared to a traditional standing frame.

Methods

17 patients with acquired brain injury (<1 year post-injury) performed two sessions in each standing device on four separate days. Maximum standing time was 30 min, less when symptoms of syncope or volitional exhaustion occurred. Besides total standing time, electromyography of thigh muscles, and changes in mean arterial pressure and heart rate were monitored at rest and during standing.

Results

No significant differences were found in standing time, changes in mean arterial pressure or heart rate between standing in Innowalk Pro and the standing frame. However, participants had significantly more thigh muscle activation (p = 0.006) when standing in Innowalk Pro.

Conclusions

Mobilising participants with a subacute acquired brain injury in a standing frame with motorised passive movements of the lower limbs did, despite higher thigh muscle activation, not lead to better orthostatic tolerance or prolonged standing time compared to a traditional standing frame.

The use of assisted technologies in early aggressive mobilization with an individual in a minimally conscious state: a case report

INTRODUCTION

Early neurorehabilitation and passive, upright mobilization strategies have been shown to be beneficial for individuals with disorders of consciousness (DOC). However, literature is limited in illustrating the use of an early, aggressive program with an added focus on dynamic and active upright mobilization. The purpose of this case report is to describe a two-week aggressive, upright standing and walking program with an individual with traumatic brain injury in an acute inpatient rehabilitation setting. The case investigates the association between aggressive mobilization with changes in level of consciousness and daily cognitive, motor and communicative behaviours.

CASE DESCRIPTION

A 30-year-old male classified in DOC as minimally conscious state (MCS) participated in an early upright mobilization program. The two-week intervention consisted of aggressive static/passive and dynamic/active upright mobilization activities, involving a multidisciplinary rehabilitation team. Expressive communication, motor responses and current level of consciousness were monitored and assessed twice a day. Additionally, the patient's activation and arousal were subjectively monitored during daily therapy sessions.

RESULTS

Following the dynamic/active mobilization activities, the patient demonstrated improved expressive communication, motor scores and increased activation and arousal during the mobilizations. After the two-week intervention, he emerged from DOC.

CONCLUSION

This case report illustrates intense, more active/dynamic upright mobilization with the use of assisted technologies provides promise as an effective intervention for improving communication, motor responses, arousal and level of consciousness in a patient in MCS. Initiating upright, active activity sooner in the recovery process, may lead to improved outcomes and quicker emergence.IMPLICATIONS FOR REHABILITATIONAggressive upright mobilization may be delivered safely to patients in DOC early in their rehabilitative care.Aggressive upright mobilization may be beneficial for patients in DOC.Higher intensity, more active/dynamic upright mobilization such as the use of Erigo®Pro + stepping and locomotor training on a treadmill with body weight support demonstrated positive outcomes with expressive communication, motor responses and arousal.Earlier initiation of aggressive mobilization may promote recovery.

Early passive orthostatic training prevents diaphragm atrophy and dysfunction in intensive care unit patients on mechanical ventilation: A retrospective case‒control study

BACKGROUND

Intensive care unit (ICU) patients on mechanical ventilation (MV), who are always bedridden, easily develop diaphragm atrophy and dysfunction. However, few studies have assessed diaphragmatic thickness and functional changes after early passive orthostatic training.

OBJECTIVES

This is the first study to investigate the efficacy of early passive orthostatic training in preventing diaphragm atrophy and dysfunction in ICU patients on MV.

METHODS

In this randomized retrospective case‒control study, 81 ICU patients on MV for 8 days or longer were enrolled. Forty-four patients received early passive orthostatic training initiated within 72 h of MV initiation (training group), and 37 patients did not receive training (no-training group). The protocol was performed for seven days, once a day for 30 min. The primary outcomes were diaphragmatic thickness and diaphragm contractile fraction (TFdi). The ventilatory parameters were secondary outcomes.

RESULTS

This study included 81 (45 male) ICU patients on MV [(mean ± SD) age = (60.63 ± 7.88) years]. The training group had a larger diaphragmatic thickness at end-expiration (Tdi_,ee) and a smaller magnitude of decrease in Tdi_,ee and TFdi (p = 0.001, 0.029, and <0.001, respectively) than the no-training group after 7 days of training. The mean arterial pressure, fraction of inspired oxygen, and white blood cell levels were decreased in the training group compared with the no-training group (p = 0.003, 0.001, and 0.026, respectively), but lactic acid levels decreased slightly in the training group with no significant difference (p = 0.708).

CONCLUSIONS

Early passive orthostatic training is suitable to ameliorate diaphragm atrophy and dysfunction in ICU patients on MV.

Effect of robotic tilt table verticalization on recovery in patients with disorders of consciousness: a randomized controlled trial

Verticalization is a common therapeutic intervention during rehabilitation of patients with disorders of consciousness (DoC). The Erigo®Pro is a robotic tilt-table (RTT) with built-in stepping unit for the lower extremities to prevent orthostatic hypotension during verticalization. In addition, the system also provides functional electrical stimulation (FES) of muscles of the lower extremities. In this randomized controlled clinical trial (RCT), 47 patients with subacute DoC received a 4-week verticalization regime (16 verticalization sessions) and were allocated to one of three experimental groups: (1) verticalization by means of RTT with FES, (2) by means of RTT without FES, or (3) by conventional physiotherapy (CPT). Level of consciousness (LoC), spasticity, functional independence in daily activities, and functional brain connectivity measured by means of high-density quantitative EEG were assessed at baseline, directly after the verticalization program and after 6 months. There was a similar clinical improvement in all three experimental groups. RTT was not associated with an effect on any of the clinical outcomes. Verticalization or mobilization time during the study period was significantly positively correlated with recovery of consciousness (rho = 0.494, p < 0.001) in the short term and showed a statistical trend at the 6 months follow-up (rho = 0.244, p = 0.078). In conclusion, RTT treatment is not more effective in promoting recovery of consciousness than CPT in subacute DoC patients. Yet, our data suggest, that verticalization may be an important and feasible rehabilitation intervention in this group of patients. ClinicalTrials.gov NCT Number NCT02639481, registered on December 24, 2015.

Statistical analysis plan: Early mobilization by head-up tilt with stepping versus standard care after severe traumatic brain injury

Background

Early mobilization on a tilt table with stepping versus standard care may be beneficial for patients with severe brain injury, but data from randomized clinical trials are lacking. This detailed statistical analysis plan describes the analyses of data collected in a randomized clinical feasibility trial for early mobilization by head-up tilt with stepping versus standard care after severe traumatic brain injury.

Methods

Primary feasibility outcomes are the proportion of included participants who were randomized out of all screened patients; the proportion of participants allocated to the experimental intervention who received at least 60% of the planned exercise sessions; and safety outcomes such as adverse events and reactions and serious adverse events and reactions. Exploratory clinical outcomes are suspected unexpected serious adverse reactions; and functional outcomes as assessed by the Coma Recovery Scale-Revised at four weeks; Early Functional Ability Scale and Functional Independence Measure at three months. The description includes the statistical analysis plan, including the use of multiple imputations and Trial Sequential Analysis.

Neurologic and musculoskeletal effects of tilt-table standing on adults: a systematic review

[Purpose] Tilt table use is associated, most often, with the assessment of syncope. However, it also has applications for patients with neurologic and orthopedic problems. These applications do not appear to be widely applied. The purpose of this review, therefore, was to summarize the research literature addressing the use of tilt tables for treating specific musculoskeletal and neurologic impairments in adults. [Methods] Relevant literature was identified by searches of the PubMed, CINAHL, and Scopus databases and hand searches (December 2018 and October 2020). The methodological quality of the identified research articles was assessed using the PEDro scale. [Results] Of 482 unique articles identified, 20 matched the eligibility criteria of the review and were included. The studies varied widely in the populations studied, procedures used, and responses reported. The studies provide limited support for tilt table standing as an intervention. [Conclusion] However, evidence that some patients with neurologic conditions may respond positively to tilt-table standing is available. Among such individuals are those with decreased ankle range of motion, positive neurologic signs in the lower limbs, and decreased levels of consciousness.

Dynamic cerebral autoregulation during early orthostatic exercise in patients with severe traumatic brain injury: Further exploratory analyses from a randomized clinical feasibility trial

In patients with severe traumatic brain injury, there is limited evidence of the clinical effect of early orthostatic exercise, although such exercise may strengthen systemic or cerebral hemodynamic responses to head-up tilt, thereby minimizing orthostatic intolerance. We measured dynamic cerebral autoregulation (dCA) and the occurrence of orthostatic intolerance after four weeks of regular orthostatic exercise by head-up tilt using a tilt table with integrated stepping using the ERIGO® tilt-table and comparing it to standard care. Thirty-four patients with severe traumatic brain injury admitted to a neurocritical care unit were included in this randomized clinical trial. Middle cerebral artery blood flow velocity (MCAv), non-invasive mean arterial pressure, heart rate and PaCO₂ were recorded; dCA was measured by the non-invasive mean flow index (nMxa). Transition from the supine position to head-up tilt triggered a 10-16% decrease in MCAv and increased nMxa in both groups at all time points (P < 0.05), with no differences between groups. There was no difference in the number of episodes with orthostatic intolerance (5 vs 3; 1 vs 2; 1 vs 0) at baseline, two weeks and four weeks, respectively, and no association between changes in PaCO₂-adjusted nMxa and the occurrence of orthostatic reactions (P = 0.35). Early orthostatic exercise does not affect dynamic cerebral autoregulation and does not protect against orthostatic intolerance in patients with severe traumatic brain injury. Trial registration: ClinicalTrials.gov identifier: NCT02924649. Registered on 3rd October 2016.

Conservative rehabilitation for a patient presenting with severe orthostatic hypotension after surgical management of brainstem tumor: illustrative case

BACKGROUND

Blood pressure (BP) dysregulation is frequently observed in patients after surgical management of brainstem lesions; however, there has been no standard rehabilitation. Considering the conflicting risks for hypoperfusion and disuse syndrome in these patients, a safe and effective rehabilitative strategy is warranted.

OBSERVATIONS

A 50-year-old man who had undergone craniotomy for resection of a recurrent dorsal medullary epidermoid cyst developed persistent orthostatic hypotension. It was resistant to physical exercise, pharmacological therapy, abdominal binders, and compression stockings; therefore, it inhibited postoperative rehabilitation. Although the responsible lesion was not clearly visible on the postoperative image, accompanying symptoms, including segmental sensory impairment, implied an improvement in BP control. Although there was a trade-off between the risk of developing disuse syndrome and a delay in functional recovery, the authors decided to continue a conservative rehabilitation strategy rather than increasing the workload. The patient’s BP control was gradually restored by the seventh postoperative week, and the authors proceeded with basic activity training.

LESSONS

A conservative prognostic prediction-based rehabilitation strategy was applied in this case. The precise evaluation of the accompanying neurological symptoms was helpful in deciding the treatment regimen. The conflicting risks for hypoperfusion and disuse syndrome in such cases must be considered.

Early Orthostatic Exercise by Head-Up Tilt With Stepping vs. Standard Care After Severe Traumatic Brain Injury Is Feasible

Background: Intensive rehabilitation of patients after severe traumatic brain injury aims to improve functional outcome. The effect of initiating rehabilitation in the early phase, in the form of head-up mobilization, is unclear.

Objective: To assess whether early mobilization is feasible and safe in patients with traumatic brain injury admitted to a neurointensive care unit.

Methods: This was a randomized parallel-group clinical trial, including patients with severe traumatic brain injury (Glasgow coma scale <11 and admission to the neurointensive care unit). The intervention consisted of daily mobilization on a tilt-table for 4 weeks. The control group received standard care. Outcomes were the number of included participants relative to all patients with traumatic brain injury who were approached for inclusion, the number of conducted mobilization sessions relative to all planned sessions, as well as adverse events and reactions. Information on clinical outcome was collected for exploratory purposes.

Results: Thirty-eight participants were included (19 in each group), corresponding to 76% of all approached patients [95% confidence interval (CI) 63–86%]. In the intervention group, 74% [95% CI 52–89%] of planned sessions were carried out. There was no difference in the number of adverse events, serious adverse events, or adverse reactions between the groups.

Conclusions: Early head-up mobilization is feasible in patients with severe traumatic brain injury. Larger randomized clinical trials are needed to explore potential benefits and harms of such an intervention.

Clinical Trial Registration: [ClinicalTrials.gov], identifier [NCT02924649]. Registered on 3rd October 2016.

Effectiveness of non-pharmacological interventions to treat orthostatic hypotension in elderly people and people with a neurological condition: a systematic review

OBJECTIVE

The objective of this review was to summarize the best available evidence regarding the effectiveness of non-pharmacological interventions to treat orthostatic hypotension (OH) in elderly people and people with a neurological condition.

INTRODUCTION

Orthostatic hypotension is common in elderly people and people with a neurological condition and can interfere with or limit rehabilitation. Non-pharmacological interventions to treat OH could allow for longer and earlier mobilization, which is recommended in national clinical guidelines for rehabilitation in the acute or sub-acute phase following stroke or other neurological conditions.

INCLUSION CRITERIA

The review considered people aged 50 years and older, and people aged 18 years and elderly people with a neurological condition. Non-pharmacological interventions to treat OH included compression garments, neuromuscular stimulation, physical counter-maneuvers, aerobic or resistance exercises, sleeping with head tilted up, increasing fluid and salt intake, and timing and size of meals. The comparator was usual care, no intervention, pharmacological interventions, or other non-pharmacological interventions. Outcome measures included systolic blood pressure, diastolic blood pressure, heart rate, cerebral blood flow, observed/perceived symptoms, duration of standing or sitting in minutes, tolerance of therapy, functional ability, and adverse events/effects.

METHODS

Databases for published and unpublished studies available in English up to April 2018 with no lower date limit were searched. Critical appraisal was conducted using standardized instruments from JBI. Data were extracted using standardized tools designed for quantitative studies. Where appropriate, studies were included in a meta-analysis; otherwise, data were presented in a narrative form due to heterogeneity.

RESULTS

Forty-three studies - a combination of randomized controlled trials (n = 13), quasi-experimental studies (n = 28), a case control study (n = 1), and a case report (n = 1) - with 1069 participants were included. Meta-analyses of three interventions (resistance exercise, electrical stimulation, and lower limb compression bandaging) showed no significant effect of these interventions. Results from individual studies indicated physical maneuvers such as leg crossing, leg muscle pumping/contractions, and bending forward improved orthostatic hypotension. Abdominal compression improved OH. Sleeping with head up in combination with pharmacological treatment was more effective than sleeping with head up alone. Eating smaller, more frequent meals was effective. Drinking 480 mL of water increased blood pressure.

CONCLUSIONS

The review found mixed results for the effectiveness of non-pharmacological interventions to treat OH in people aged 50 years and older, and people with a neurological condition. There are several non-pharmacological interventions that may be effective in treating OH, but not all have resulted in clinically meaningful changes in outcome. Some may not be suitable for people with moderate to severe disability; therefore, it is important for clinicians to consider the patient's abilities and impairments when considering which non-pharmacological interventions to implement.

Early mobilization of a patient with acquired brain injury using a new standing aid, the Innowalk Pro. A single subject experimental design

BACKGROUND

Early mobilization is regarded as important in patients with severe acquired brain injury.

OBJECTIVE

To explore the feasibility, physical and physiological responses of using a new assistive, electric standing device, Innowalk Pro (IP), that passively moves the legs in an upright position.

DESIGN

A single-subject experimental design.

METHODS

A three-phase model (A₁-B-A₂) was chosen; A₁: baseline using a standing frame, B: an intervention using IP and A₂: withdrawal using a standing frame. Outcome measures: Patient's and assistive personnel's experiences with Likert scales, Modified Trunk Impairment Scale, Modified Ashworth Scale (MAS), Lidcombe Template (passive ankle dorsiflexion), duration of the training, blood pressure and heart rate.

RESULTS

A 40-year-old female, with subarachnoid haemorrhage, perceived training in the IP as more physically exhausting than training in a standing frame, influencing the training time. However, she preferred the IP over the standing frame. Trunk control did not improve, until the withdrawal phase. A small MAS reduction in ankle plantar flexors was maintained in the A₂-phase. The heart rate showed an ascending trend in A₁, and a non-significant descending trend in B- and A₂-phases. Blood pressure showed a flat trend line in A₁ and B-phases, and a descending trend in A₂.

CONCLUSION

The new IP was considered a feasible and motivating intervention. Heart rate tended to decrease during IP training, while the blood pressure remained stable. Further research is needed to evaluate whether the IP should be a preferable or a supplementary assistive device for early mobilization.Implications for rehabilitationA new electrical standing device, Innowalk Pro, which moves the legs in upright position, was found to be feasible in early mobilisation of a patient with severe brain injury.Trained physiotherapist and assistive personnel are recommended for safe training.Physiological responses like heart rate and blood pressure remained relatively stable when training in Innowalk Pro.We question whether the leg movements when standing in Innowalk Pro, may contribute to improvement in trunk control.

Early head-up mobilisation versus standard care for patients with severe acquired brain injury: A systematic review with meta-analysis and Trial Sequential Analysis

BACKGROUND

There is increasing focus on earlier rehabilitation in patients with traumatic or hypoxic brain injury or stroke. This systematic review evaluates the benefits and harms of early head-up mobilisation versus standard care in patients with severe acquired brain injury.

METHODS

We searched Medline, CENTRAL, EMBASE, four other databases and 13 selected clinical trial registries until April 2020. Eligible randomised clinical trials compared early head-up mobilisation versus standard care in patients with severe acquired brain injury and were analysed conducting random- and fixed-effects meta-analyses and Trial Sequential Analysis (TSA). Certainty of evidence was assessed by GRADE.

MAIN RESULTS

We identified four randomised clinical trials (total n = 385 patients) with severe acquired brain injury (stroke 86% and traumatic brain injury 13%). Two trials were at low risk and two at high risk of bias. We found no evidence of a difference between early mobilisation vs. standard care on mortality or poor functional outcome at end of the intervention (relative risk (RR) 1.19, 95% CI 0.93 to 1.53; I2 0%; very low certainty) or at maximal follow-up (RR 1.03, 95% CI 0.89 to 1.21; I2 0%; very low certainty). We found evidence against an effect on quality of life at maximal follow-up. The proportion of patients with at least one serious adverse event did not differ at end of intervention or at maximal follow-up. For most comparisons, TSA suggested that further trials are needed.

CONCLUSIONS

We found no evidence of a difference between early mobilisation versus standard care for patients with severe acquired brain injury. Early mobilisation appeared not to exert a major impact on quality of life. This systematic review highlights the insufficient evidence in patients with severe brain injury, and no firm conclusions can be drawn from these data.

TRIAL REGISTRATION

Protocol uploaded to PROSPERO: April 2018 (revised October 2018, CRD42018088790).

Comparison between Erigo tilt-table exercise and conventional physiotherapy exercises in acute stroke patients: a randomized trial

Background

Stroke is a common, serious, and disabling health-care problem throughout the world. Although great advances have been made in acute stroke management, the most of post-stroke care to reduce a patient’s dependency relies on rehabilitation.

Purpose

To compare the effectiveness of exercises using an Erigo tilt-table and conventional physiotherapy in the rehabilitation of acute stroke patients.

Methods

A total of 110 acute stroke patients (age 51.08 ± 7.48 years, 8.69 ± 4.62 days after stroke) were assigned randomly into two groups, 55 in each for 30 days of conventional physiotherapy (Group A) or Erigo tilt-table (Group B) rehabilitation. The National Institutes of Health Stroke Scale (NIHSS), Mini-Mental Scale Examination (MMSE), Modified Ashworth Scale were used to measure muscle tone, quality of life (QOL) and muscle strength (MMT), Affected upper (UE) and lower limb (LE) outcomes were assessed at baseline (day 0), after day 30 of the intervention and on 90th day of follow up. Repeated measures ANOVA followed by a Bonferroni post-hoc test and independent Student’s t-test were used for statistical analysis to evaluate the improvement in outcome variables within and between the groups.

Results

Both the treatments were effective. Notably, Group B patients showed a significant improvement in both QOL (p < 0.001) and lower limb strength (p = 0.030) at day 90 and muscle tone (p = 0.011) at day 30 compared to Group A.

Conclusion

Both the groups improved with time but the Erigo tilt-table group experienced greater improvement in QOL, NIHSS and muscle strength of the lower limb. Thus, Erigo tilt-table can be used for early rehabilitation of acute hemiplegic patients and improving their quality of life and motor system, resulting in better functional performances.

[Evaluation of the efficacy and safety of application of the drug cortexin in the complex rehabilitation of verticalization in patients with ischemic stroke in the acute period]

AIM

To evaluate the efficacy and safety of cortexin in the complex of rehabilitation measures for verticalization in patients with ischemic stroke in the acute period.

MATERIAL AND METHODS

The study included 90 patients with hemispheric ischemic stroke. Patients of the first group (n=30) received cortexin in a dose of 20 mg per day intramuscularly for 10 days, along with basic therapy during early verticalization. Patients of the second group (n=30) received basic therapy during early verticalization and patients of the third group (n=30) received only basic therapy without verticalization. To assess the severity of condition, NIHSS, modified Rankin scale, the Barthel index, the Rivermead mobility index, MMSE, MOCA were used. To study cardiovascular function in patients, the segmental part of the autonomic nervous system was studied: a test with isometric load, a Valsalva test, a test based on the change in heart rate with slow deep breathing. All studies were conducted before and 10-14 days after treatment.

RESULTS AND CONCLUSION

The most complete regression of neurological deficits and manifestations of cardiac autonomic neuropathy during the acute period of ischemic stroke was observed in the group of patients treated with cortexin (20 mg per day for 10 days), along with basic therapy and early verticalization, compared to the groups, which received basic therapy with early verticalization or basic therapy without verticalization.

Effect of verticalization with Erigo® in the acute rehabilitation of severe acquired brain injury

The recovery of the orthostatism after a severe acquired brain injury (sABI) is an essential objective to pursue in order to avoid the occurrence of secondary complications resulting from prolonged immobilization to which the patient is subjected during the acute phase. This randomized controlled trial aims to evaluate the effect of verticalization with the lower limb robot-assisted training system Erigo® versus conventional neurorehabilitation in 44 adult subjects affected by sequelae of sABI in the acute rehabilitation phase, related to cardiorespiratory signs and measures of impairment and activity. At the end of the study (20 treatment sessions, 5 sessions per week), in both groups of patients, there were no dropouts nor adverse events. In subject verticalized with Erigo®, there were no episodes of (pre)syncope from orthostatic hypotension nor postural orthostatic tachycardia and cardiorespiratory signs remained stable; moreover, there were no increase in muscle tone nor reduction in range of motion at lower limbs. Results obtained show improved outcomes on the whole and in a similar way in both groups; however, the improvement in scores of the National Institutes of Health Stroke Scale, the Tinetti scale, and the Functional Independence Measure from the enrollment to the end of the treatment cycle being equal, the evaluation performed at the 10th session allows to establish that the improvement appears earlier in the intervention group and later in the control group. The more rapid recovery of impairments and some activities in subjects treated with Erigo® could allow a "time-saver" to devote to the rehabilitation of sensory-motor functions which are more complex and subordinated to the preliminary reacquisition of elementary postures and motor strategies.

Intravenous saline administration in patients with severe acquired brain injury and orthostatic intolerance for tilt-table mobilization

PRIMARY OBJECTIVE

This study aimed to investigate the effect of intravenous saline administration on orthostatic hypotension (OH) during head up tilt (HUT) and the change in the renin-angiotensin-aldosterone system before and after HUT in patients with severe acquired brain injury (ABI).

RESEARCH DESIGN

The study is designed as an observational study.

METHODS AND PROCEDURES

Fourteen patients with ABI, low level of consciousness and OH were monitored before, during and after HUT with non-invasive beat-to-beat blood pressure measurement, and transcranial Doppler determination of middle cerebral artery blood flow velocity. Blood samples were collected before and after two HUT sessions separated by 1 hour and saline was administered in between.

MAIN OUTCOMES AND RESULTS

Patients' ability to stand upright did not change after saline administration due to OH. The patients showed signs of reduced cerebral autoregulation at both HUT sessions. The patients had a significant lower level of renin and angiotensin II but not aldosterone.

CONCLUSIONS

Patients with severe ABI and OH demonstrate no improvement in standing time with reduced plasma renin and angiotensin II after two HUT sessions and 1 hour fluid administration. Research focusing on the ability to retain fluid after bed rest is warranted.

Distinctive Steady-State Heart Rate and Blood Pressure Responses to Passive Robotic Leg Exercise during Head-Up Tilt: A Pilot Study in Neurological Patients

Introduction: Robot-assisted tilt table therapy was proposed for early rehabilitation and mobilization of patients after diseases such as stroke. A robot-assisted tilt table with integrated passive robotic leg exercise (PE) mechanism has the potential to prevent orthostatic hypotension usually provoked by verticalization. In a previous study with rather young healthy subjects [average age: 25.1 ± 2.6 years (standard deviation)], we found that PE effect on the cardiovascular system depends on the verticalization angle of the robot-assisted tilt table. In the current study, we investigated in an older population of neurological patients (a) whether they show the same PE effects as younger healthy population on the cardiovascular system at different tilt angles, (b) whether changing the PE frequency (i.e., stepping speed) influences the PE effect on the cardiovascular system, (c) whether PE could prevent orthostatic hypotension, and finally, (d) whether PE effect is consistent from day to day.

Methods: Heart rate (HR), and systolic and diastolic blood pressures (sBP, dBP) in response to PE at two different tilt angles (α = 20°, 60°) with three different PE frequencies (i.e., 0, 24, and 48 steps per minute) of 10 neurological patients [average age: 68.4 ± 13.5 years (standard deviation)] were measured on 2 consecutive days. Linear mixed models were used to develop statistical models and analyze the repeated measurements.

Results: The models show that: PE significantly increased sBP and dBP but had no significant effect on HR. (a) Similar to healthy subjects the effect of PE on sBP was dependent on the tilt angle with higher tilt angles resulting in a higher increase. Head-up tilting alone significantly increased HR and dBP but resulted in a non-significant drop in sBP. PE, in general, had a more additive effect on increasing BP. (b) The effect of PE was not influenced by its speed. (c) Neither during head-up tilt alone nor in combination with PE did participants experience orthostatic hypotension. (d) The measurement day was not a statistically significant factor regarding the effects of verticalization and PE on the cardiovascular response.

Conclusion: We provide evidence that PE can increase steady-state values of sBP and dBP in neurological patients during head-up tilt. Similar to healthy subjects the effect on sBP depends on the verticalization angle of the robot-assisted tilt table. PE might have the potential to prevent orthostatic hypotension, but as the amount of drop in BP in response to head-up tilting was not leading to orthostatic hypotension in our patients, we could neither conclude nor reject such a preventive compensatory effect. Furthermore, we found that changing the PE speed does not influence the steady-state cardiovascular response.

[Concepts boosting the clinical impact in early neurological rehabilitation]

Vaudois university hospital in Lausanne, Switzerland, has an acute neurological rehabilitation unit. An interdisciplinary team cares for patients with brain injuries after their transfer from intensive care. In this context, nurses base their practice on different concepts and techniques for introducing early neurological rehabilitation into each care procedure.

Modeling the effect of tilting, passive leg exercise, and functional electrical stimulation on the human cardiovascular system

Long periods of bed rest negatively affect the human body organs, notably the cardiovascular system. To avert these negative effects and promote functional recovery in patients dealing with prolonged bed rest, the goal is to mobilize them as early as possible while controlling and stabilizing their cardiovascular system. A robotic tilt table allows early mobilization by modulating body inclination, automated passive leg exercise, and the intensity of functional electrical stimulation applied to leg muscles (inputs). These inputs are used to control the cardiovascular variables heart rate (HR), and systolic and diastolic blood pressures (sBP, dBP) (outputs). To enhance the design of the closed-loop cardiovascular biofeedback controller, we investigated a subject-specific multi-input multi-output (MIMO) black-box model describing the relationship between the inputs and outputs. For identification of the linear part of the system, two popular linear model structures-the autoregressive model with exogenous input and the output error model-are examined and compared. The estimation algorithm is tested in simulation and then used in four study protocols with ten healthy participants to estimate transfer functions of HR, sBP and dBP to the inputs. The results show that only the HR transfer functions to inclination input can explain the variance in the data to a reasonable extent (on average 69.8%). As in the other input types, the responses are nonlinear; the models are either not reliable or explain only a negligible amount of the observed variance. Analysis of both, the nonlinearities and the occasionally occurring zero-crossings, is necessary before designing an appropriate MIMO controller for mobilization of bedridden patients.

Distinctive Steady-State Heart Rate and Blood Pressure Responses to Passive Robotic Leg Exercise and Functional Electrical Stimulation during Head-Up Tilt

Introduction: Tilt tables enable early mobilization of patients by providing verticalization. But there is a high risk of orthostatic hypotension provoked by verticalization, especially after neurological diseases such as spinal cord injury. Robot-assisted tilt tables might be an alternative as they add passive robotic leg exercise (PE) that can be enhanced with functional electrical stimulation (FES) to the verticalization, thus reducing the risk of orthostatic hypotension. We hypothesized that the influence of PE on the cardiovascular system during verticalization (i.e., head-up tilt) depends on the verticalization angle, and FES strengthens the PE influence. To test our hypotheses, we investigated the PE effects on the cardiovascular parameters heart rate (HR), and systolic and diastolic blood pressures (sBP, dBP) at different angles of verticalization in a healthy population.

Methods: Ten healthy subjects on a robot-assisted tilt table underwent four different study protocols while HR, sBP, and dBP were measured: (1) head-up tilt to 60° and 71° without PE; (2) PE at 20°, 40°, and 60° of head-up tilt; (3) PE while constant FES intensity was applied to the leg muscles, at 20°, 40°, and 60° of head-up tilt; (4) PE with variation of the applied FES intensity at 0°, 20°, 40°, and 60° of head-up tilt. Linear mixed models were used to model changes in HR, sBP, and dBP responses.

Results: The models show that: (1) head-up tilt alone resulted in statistically significant increases in HR and dBP, but no change in sBP. (2) PE during head-up tilt resulted in statistically significant changes in HR, sBP, and dBP, but not at each angle and not always in the same direction (i.e., increase or decrease of cardiovascular parameters). Neither adding (3) FES at constant intensity to PE nor (4) variation of FES intensity during PE had any statistically significant effects on the cardiovascular parameters.

Conclusion: The effect of PE on the cardiovascular system during head-up tilt is strongly dependent on the verticalization angle. Therefore, we conclude that orthostatic hypotension cannot be prevented by PE alone, but that the preventive effect depends on the verticalization angle of the robot-assisted tilt table. FES (independent of intensity) is not an important contributing factor to the PE effect.

Sympathetic activity and early mobilization in patients in intensive and intermediate care with severe brain injuries: a preliminary prospective randomized study

Background

Patients who experience severe brain injuries are at risk of secondary brain damage, because of delayed vasospasm and edema. Traditionally, many of these patients are kept on prolonged bed rest in order to maintain adequate cerebral blood flow, especially in the case of subarachnoid hemorrhage. On the other hand, prolonged bed rest carries important morbidity. There may be a clinical benefit in early mobilization and our hypothesis is that early gradual mobilization is safe in these patients. The aim of this study was to observe and quantify the changes in sympathetic activity, mainly related to stress, and blood pressure in gradual postural changes by the verticalization robot (Erigo®) and after training by a lower body ergometer (MOTOmed-letto®), after prolonged bed rest of minimum 7 days.

Methods

Thirty patients with severe neurological injuries were randomized into 3 groups with different protocols of mobilization: Standard, MOTOmed-letto® or Erigo® protocol. We measured plasma catecholamines, metanephrines and blood pressure before, during and after mobilization.

Results

Blood pressure does not show any significant difference between the 3 groups. The analysis of the catecholamines suggests a significant increase in catecholamine production during Standard mobilization with physiotherapists and with MOTOmed-letto® and no changes with Erigo®.

Conclusions

This preliminary prospective randomized study shows that the mobilization of patients with severe brain injuries by means of Erigo® does not increase the production of catecholamines. It means that Erigo® is a well-tolerated method of mobilization and can be considered a safe system of early mobilization of these patients. Further studies are required to validate our conclusions.

Trial registration

The study was registered in the ISRCTN registry with the trial registration number ISRCTN56402432. Date of registration: 08.03.2016. Retrospectively registered.

Effectiveness of a Very Early Stepping Verticalization Protocol in Severe Acquired Brain Injured Patients: A Randomized Pilot Study in ICU

BACKGROUND AND OBJECTIVE

Verticalization was reported to improve the level of arousal and awareness in patients with severe acquired brain injury (ABI) and to be safe in ICU. We evaluated the effectiveness of a very early stepping verticalization protocol on their functional and neurological outcome.

METHODS

Consecutive patients with Vegetative State or Minimally Conscious State were enrolled in ICU on the third day after an ABI. They were randomized to undergo conventional physiotherapy alone or associated to fifteen 30-minute sessions of verticalization, using a tilt table with robotic stepping device. Once stabilized, patients were transferred to our Neurorehabilitation unit for an individualized treatment. Outcome measures (Glasgow Coma Scale, Coma Recovery Scale revised -CRSr-, Disability Rating Scale-DRS- and Levels of Cognitive Functioning) were assessed on the third day from the injury (T0), at ICU discharge (T1) and at Rehab discharge (T2). Between- and within-group comparisons were performed by the Mann-Whitney U test and Wilcoxon signed-rank test, respectively.

RESULTS

Of the 40 patients enrolled, 31 completed the study without adverse events (15 in the verticalization group and 16 in the conventional physiotherapy). Early verticalization started 12.4±7.3 (mean±SD) days after ABI. The length of stay in ICU was longer for the verticalization group (38.8 ± 15.7 vs 25.1 ± 11.2 days, p = 0.01), while the total length of stay (ICU+Neurorehabilitation) was not significantly different (153.2 ± 59.6 vs 134.0 ± 61.0 days, p = 0.41). All outcome measures significantly improved in both groups after the overall period (T2 vs T0, p<0.001 all), as well as after ICU stay (T1 vs T0, p<0.004 all) and after Neurorehabilitation (T2 vs T1, p<0.004 all). The improvement was significantly better in the experimental group for CRSr (T2-T0 p = 0.033, T1-T0 p = 0.006) and (borderline) for DRS (T2-T0 p = 0.040, T1-T0 p = 0.058).

CONCLUSIONS

A stepping verticalization protocol, started since the acute stages, improves the short-term and long-term functional and neurological outcome of ABI patients.

TRIAL REGISTRATION

clinicaltrials.gov NCT02828371.

Impaired Cerebral Autoregulation during Head Up Tilt in Patients with Severe Brain Injury

Early mobilization is of importance for improving long-term outcome for patients after severe acquired brain injury. A limiting factor for early mobilization by head-up tilt is orthostatic intolerance. The purpose of the present study was to examine cerebral autoregulation in patients with severe acquired brain injury and a low level of consciousness. Fourteen patients with severe acquired brain injury and orthostatic intolerance and fifteen healthy volunteers were enrolled. Blood pressure was evaluated by pulse contour analysis, heart rate and RR-intervals were determined by electrocardiography, middle cerebral artery velocity was evaluated by transcranial Doppler, and near-infrared spectroscopy determined frontal lobe oxygenation in the supine position and during head-up tilt. Cerebral autoregulation was evaluated as the mean flow index calculated as the ratio between middle cerebral artery mean velocity and estimated cerebral perfusion pressure. Patients with acquired brain injury presented an increase in mean flow index during head-up tilt indicating impaired autoregulation (P < 0.001). Spectral analysis of heart rate variability in the frequency domain revealed lower magnitudes of ~0.1 Hz spectral power in patients compared to healthy controls suggesting baroreflex dysfunction. In conclusion, patients with severe acquired brain injury and orthostatic intolerance during head-up tilt have impaired cerebral autoregulation more than one month after brain injury.

Tilt Table Therapies for Patients with Severe Disorders of Consciousness: A Randomized, Controlled Trial

One major aim of the neurological rehabilitation of patients with severe disorders of consciousness (DOC) is to enhance patients' arousal and ability to communicate. Mobilization into a standing position by means of a tilt table has been shown to improve their arousal and awareness. However, due to the frequent occurrence of syncopes on a tilt table, it is easier to accomplish verticalization using a tilt table with an integrated stepping device. The objective of this randomized controlled clinical trial was to evaluate the effectiveness of a tilt table therapy with or without an integrated stepping device on the level of consciousness. A total of 50 participants in vegetative or minimally conscious states 4 weeks to 6 month after injury were treated with verticalization during this randomized controlled trial. Interventions involved ten 1-hour sessions of the specific treatment over a 3-week period. Blinded assessors made measurements before and after the intervention period, as well as after a 3-week follow-up period. The coma recovery scale-revised (CRS-R) showed an improvement by a median of 2 points for the group receiving tilt table with integrated stepping (Erigo). The rate of recovery of the group receiving the conventional tilt table therapy significantly increased by 5 points during treatment and by an additional 2 points during the 3-week follow-up period. Changes in spasticity did not significantly differ between the two intervention groups. Compared to the conventional tilt table, the tilt table with integrated stepping device failed to have any additional benefit for DOC patients. Verticalization itself seems to be beneficial though and should be administered to patients in DOC in early rehabilitation. Trial Registration: Current Controlled Trials Ltd (www.controlled-trials.com), identifier number ISRCTN72853718.

Systematic review and clinical recommendations for dosage of supported home-based standing programs for adults with stroke, spinal cord injury and other neurological conditions

Background

Sitting for more than 8 h a day has been shown to negatively impact health and mortality while standing is the recommended healthier alternative. Home-based standing programs are commonly recommended for adults who cannot stand and/or walk independently. The aim of this systematic review is to review effectiveness of home-based standing programs for adults with neurological conditions including stroke and spinal cord injury; and to provide dosage guidelines to address body structure and function, activity and participation outcomes.

Methods

Eight electronic databases were searched, including Cochrane Library databases, MEDLINE, CINAHL and EMBASE. From 376 articles, 36 studies addressing impact of a standing intervention on adults with sub-acute or chronic neurological conditions and published between 1980 and September 2015 were included. Two reviewers independently screened titles, reviewed abstracts, evaluated full-text articles and rated quality and strength of evidence. Evidence level was rated using Oxford Centre for Evidence Based Medicine Levels and quality evaluated using a domain-based risk-of-bias rating. Outcomes were divided according to ICF components, diagnoses and dosage amounts from individual studies. GRADE and the Evidence-Alert Traffic-Lighting system were used to determine strength of recommendation and adjusted in accordance with risk-of-bias rating.

Results

Stronger evidence supports the impact of home-based supported standing programs on range of motion and activity, primarily for individuals with stroke or spinal cord injury while mixed evidence supports impact on bone mineral density. Evidence for other outcomes and populations is weak or very weak.

Conclusions

Standing should occur 30 min 5 times a week for a positive impact on most outcomes while 60 min daily is suggested for mental function and bone mineral density.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0813-x) contains supplementary material, which is available to authorized users.

Quantitative EEG analysis in minimally conscious state patients during postural changes

Mobilization and postural changes of patients with cognitive impairment are standard clinical practices useful for both psychic and physical rehabilitation process. During this process, several physiological signals, such as Electroen-cephalogram (EEG), Electrocardiogram (ECG), Photopletysmography (PPG), Respiration activity (RESP), Electrodermal activity (EDA), are monitored and processed. In this paper we investigated how quantitative EEG (qEEG) changes with postural modifications in minimally conscious state patients. This study is quite novel and no similar experimental data can be found in the current literature, therefore, although results are very encouraging, a quantitative analysis of the cortical area activated in such postural changes still needs to be deeply investigated. More specifically, this paper shows EEG power spectra and brain symmetry index modifications during a verticalization procedure, from 0 to 60 degrees, of three patients in Minimally Consciousness State (MCS) with focused region of impairment. Experimental results show a significant increase of the power in β band (12 - 30 Hz), commonly associated to human alertness process, thus suggesting that mobilization and postural changes can have beneficial effects in MCS patients.

Do post-stroke patients benefit from robotic verticalization? A pilot-study focusing on a novel neurophysiological approach

BACKGROUND

Tilt-table equipped with the dynamic foot-support (ERIGO) and the functional electric stimulation could be a safe and suitable device for stabilization of vital signs, increasing patient's motivation for further recovery, decreasing the duration of hospitalization, and accelerating the adaptation to vertical posture in bedridden patients with brain-injury. Moreover, it is conceivable that verticalization may improve cognitive functions, and induce plastic changes at sensory motor and vestibular system level that may in turn facilitate motor functional recovery.

OBJECTIVE

To test the safety and effectiveness of ERIGO treatment on motor and cognitive functions, cortical plasticity within vestibular and sensory-motor systems in a bedridden post-stroke sample.

METHODS

20 patients were randomly divided in two groups that performed ERIGO training (30 sessions) (G1) or physiotherapist-assisted verticalization training (same duration) (G2), beyond conventional neurorehabilitation treatment. Motor and cognitive functions as well as sensory-motor and vestibular system plasticity were investigated either before (T0) or after (T1) the rehabilitative protocols.

RESULTS

Both the verticalization treatments were well-tolerated. Notably, the G1 patients had a significant improvement in cognitive function (p = 0.03), global motor function (p = 0.006), sensory-motor (p < 0.001) and vestibular system plasticity (p = 0.02) as compared to G2.

CONCLUSIONS

ERIGO training could be a valuable tool for the adaptation to the vertical position with a better global function improvement, as also suggested by the sensory-motor and vestibular system plasticity induction.

Early poststroke rehabilitation using a robotic tilt-table stepper and functional electrical stimulation

Background. Stroke frequently leaves survivors with hemiparesis. To prevent persistent deficits, rehabilitation may be more effective if started early. Early training is often limited because of orthostatic reactions. Tilt-table stepping robots and functional electrical stimulation (FES) may prevent these reactions. Objective. This controlled convenience sample study compares safety and feasibility of robotic tilt-table training plus FES (ROBO-FES) and robotic tilt-table training (ROBO) against tilt-table training alone (control). A preliminary assessment of efficacy is performed. Methods. Hemiparetic ischemic stroke survivors (age 58.3 ± 1.2 years, 4.6 ± 1.2 days after stroke) were assigned to 30 days of ROBO-FES (n = 38), ROBO (n = 35), or control (n = 31) in addition to conventional physical therapy. Impedance cardiography and transcranial doppler sonography were performed before, during, and after training. Hemiparesis was assessed using the British Medical Research Council (MRC) strength scale. Results. No serious adverse events occurred; 8 patients in the tilt-table group prematurely quit the study because of orthostatic reactions. Blood pressure and CBFV dipped <10% during robot training. In 52% of controls mean arterial pressure decreased by ≥20%. ROBO-FES increased leg strength by 1.97 ± 0.88 points, ROBO by 1.50 ± 0.85 more than control (1.03 ± 0.61, P < 0.05). CBFV increased in both robotic groups more than in controls (P < 0.05). Conclusions. Robotic tilt-table exercise with or without FES is safe and may be more effective in improving leg strength and cerebral blood flow than tilt table alone.

Systematic review and evidence-based clinical recommendations for dosing of pediatric supported standing programs

PURPOSE

There is a lack of evidence-based recommendations for effective dosing of pediatric supported standing programs, despite widespread clinical use.

METHODS

Using the International Classification of Functioning, Disability, and Health (Child and Youth Version) framework, we searched 7 databases, using specific search terms.

RESULTS

Thirty of 687 studies located met our inclusion criteria. Strength of the evidence was evaluated by well-known tools, and to assist with clinical decision-making, clinical recommendations based on the existing evidence and the authors' opinions were provided.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

Standing programs 5 days per week positively affect bone mineral density (60 to 90 min/d); hip stability (60 min/d in 30° to 60° of total bilateral hip abduction); range of motion of hip, knee, and ankle (45 to 60 min/d); and spasticity (30 to 45 min/d).

Effectiveness of physiotherapy and occupational therapy after traumatic brain injury in the intensive care unit

Physiotherapy and occupational therapy are frequently administered in intensive care units (ICUs) after traumatic brain injury (TBI) to promote recovery. The increasing economic pressure and the growing need for evidence of therapeutic effectiveness are reasons for reviewing the currently available scientific data. The databases of OTseeker, PEDro, Medline, and Cochrane were searched for studies on frequently applied therapeutic procedures in the ICU following a TBI. It becomes evident that the currently available data on physiotherapy and occupational therapy are very limited. Consequently, it is not possible to give conclusive recommendations within an evidence-based context. Studies of other neurological disorders indicate that early mobilisation positively influences outcome parameters such as the ability to walk. It can be concluded from three studies that physiotherapy for the prevention or treatment of ventilator-associated pneumonia is not effective. The proof of effectiveness for other physiotherapeutic and occupational therapy interventions must still be demonstrated.

Differences in the insulin tolerance test in patients with brain damage depending on posture

OBJECTIVE

The insulin tolerance test (ITT) is the gold standard for the diagnosis of GH deficiency (GHD) and hypocortisolism. As hypopituitarism is a common disorder after traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH), the test is increasingly used in patients with pre-existing brain damage.

DESIGN

A cross-sectional, observational study.

METHODS

Fifty-six patients (41 TBI and 15 SAH) were tested with the ITT (0.15 IE/kg body weight, mean glucose 33 mg/dl). In 38 patients, the test was performed in a supine position; the other 18 patients were in a sitting position during the ITT.

RESULTS

Hypocortisolism and GHD were more often diagnosed in a supine than in a sitting position (hypocortisolism: 55.3% supine versus 0% sitting, P<0.0001; GHD: 42.1% supine versus 11.1% sitting, P=0.03). Patients in a sitting position suffered more often from symptoms such as tachycardia (61.1% sitting versus 15.8% supine, P=0.001), trembling (22.2 vs 7.9%, NS), and sweating (66.7 vs 28.9%, P=0.007). There were no significant differences between the groups in drowsiness (72.2% sitting versus 65.8% supine, NS), dizziness (44.4 vs 44.7%, NS), and fatigue (33.3 vs 15.8%, NS). Because of somnolence, the hypoglycemic state could only be stopped with i.v. administration of glucose in 25 supine patients (66%). In contrast, none of the 18 patients (0%) tested in a sitting position got somnolent or was in need of i.v. application of glucose (P<0.001).

CONCLUSIONS

In patients with brain injury, posture might affect rates of diagnosing GHD and hypocortisolism and sympathetic symptoms in the ITT. These findings are exploratory and need replication in a standardized setting.