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

The Influence of Therapy Enriched with the Erigo®Pro Table and Motor Imagery on the Body Balance of Patients After Stroke-A Randomized Observational Study

PURPOSE

Impaired balance leads to loss of function, e.g., the inability to walk safely. Therefore, restoring balance is a common goal of rehabilitation after a stroke. An innovative motor imaging and robotic device, the Erigo®Pro walking table, was used to improve balance in patients who had suffered an acute stroke.

MATERIALS AND METHODS

Sixty-six stroke patients in the acute phase with an average age of 64.85 ± 18.62 years were randomly assigned to one of three groups (22 subjects each) and treated with different therapies (conventional, conventional with Erigo®Pro, and conventional with Erigo®Pro enriched with motor imaging). The duration of therapy was two weeks. Patients were assessed before and after completion of therapy. The study used the trunk stability test and the Berg Balance Scale to assess balance, and the Riablo™ device to measure static balance. In addition, an assessment of the superficial tension of the transversus abdominis and multifidus muscles was performed. The clinical trial registration URL unique identifier was NCT06276075.

RESULTS

In each of the groups studied, the therapies applied resulted in significant improvement in functional assessment of trunk stability and balance (TCT < 0.001 and BBS < 0.001). The assessment of balance in the frontal (p = 0.023) and sagittal (p = 0.074) planes with the Riablo™ device confirmed the superiority of motor imaging-enhanced therapy at the level of a statistical trend. The tension of the transversus abdominis was higher at the second measurement (M = 14.41; SE = 3.31).

CONCLUSIONS

Motor imagery-enhanced therapy is most important, both for trunk stability and functional improvement of body balance parameters and for increasing transversus abdominis muscle tension.

A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

RATIONALE

Critically ill adults are at risk for a variety of distressing and consequential symptoms both during and after an ICU stay. Management of these symptoms can directly influence outcomes.

OBJECTIVES

The objective was to update and expand the Society of Critical Care Medicine's 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.

PANEL DESIGN

The interprofessional inclusive guidelines task force was composed of 24 individuals including nurses, physicians, pharmacists, physiotherapists, psychologists, and ICU survivors. The task force developed evidence-based recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Conflict-of-interest policies were strictly followed in all phases of the guidelines, including task force selection and voting.

METHODS

The task force focused on five main content areas as they pertain to adult ICU patients: anxiety (new topic), agitation/sedation, delirium, immobility, and sleep disruption. Using the GRADE approach, we conducted a rigorous systematic review for each population, intervention, control, and outcome question to identify the best available evidence, statistically summarized the evidence, assessed the quality of evidence, and then performed the evidence-to-decision framework to formulate recommendations.

RESULTS

The task force issued five statements related to the management of anxiety, agitation/sedation, delirium, immobility, and sleep disruption in adults admitted to the ICU. In adult patients admitted to the ICU, the task force issued conditional recommendations to use dexmedetomidine over propofol for sedation, provide enhanced mobilization/rehabilitation over usual mobilization/rehabilitation, and administer melatonin. The task force was unable to issue recommendations on the administration of benzodiazepines to treat anxiety, and the use of antipsychotics to treat delirium.

CONCLUSIONS

The guidelines task force provided recommendations for pharmacologic management of agitation/sedation and sleep, and nonpharmacologic management of immobility in critically ill adults. These recommendations are intended for consideration along with the patient's clinical status.

Task-oriented robotic rehabilitation for back mobility and functioning in a post-intensive care unit obese patient: A case report

BackgroundIntensive care unit (ICU) acquired weakness is a detrimental condition characterized by muscle weakness, difficulty in weaning from mechanical ventilation, impaired mobility, and functional limitations, severely affecting overall quality of life. Obese patients face additional challenges due to obesity-related factors that exacerbate the negative effects of immobilization. Rehabilitation interventions have emerged as a crucial component of post-ICU care, but the rehabilitation management of obese patients remains challenging.Objectiveto present the impact of implementing Walker View 3.0 SCX technology in post-intensive care unit rehabilitation of obese patient.MethodsA 69-year-old Caucasian man with a BMI of 44.8 kg/m2 was referred to the Cardiopulmonary Rehabilitation Unit at Alessandria Hospital, Italy, following an ICU admission for pneumonia. After a comprehensive multidisciplinary evaluation, the patient underwent an intensive rehabilitation program including physical exercises and a personalized dietary plan. A task-oriented robotic rehabilitation was added, utilizing the Walker View 3.0 SCX, for 30 min/day, 5 days/week. The robotic rehabilitation program focused on sit-to-stand mobility with weight support initially and progressed to a weight-supported robotic treadmill.ResultsThe patient showed clear improvements in physical function, muscle strength, and independence in activity of daily living (Barthel Index improved from 15 to 70, De Morton Mobility Index improved from 8 to 39, Medical Research Council Strength improved from 17 to 40, Functional Ambulation Classification score improved from 0 to 3, Handgrip Strength Test improved from 8.8 kg to 39.4 kg). Managed by a single physiotherapist, this approach showed positive results in enhancing functional outcomes, with potential benefits in reducing operator time and assistance costs.ConclusionsIntegrating task-oriented robotic rehabilitation with Walker View 3.0 SCX showed promising outcomes for obese patients post-ICU. Personalized interventions with weight-bearing capabilities and real-time feedback optimized post-ICU care, enhancing functional outcomes, and potentially reducing operator time and assistance costs. Further research with larger samples is needed to validate the broader applicability and cost-effectiveness of robotic rehabilitation technologies in obese patients with ICU-acquired weakness.

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.

First out-of-bed mobilisation in adults with severe acquired brain injury in Scandinavian neurointensive care units: A survey of current clinical practice (FOOBScan)

BACKGROUND

The harm-benefit balance for early out-of-bed mobilisation of patients with severe acquired brain injury (ABI) in neurointensive care units (neuro-ICUs) is unclear, and there are no clinical guidelines. This study aimed to survey the current clinical practice and perceptions among clinicians involved in first out-of-bed mobilisation in Scandinavian neuro-ICUs.

METHODS

This was a cross-sectional, anonymous, web-based survey; the reporting follows the recommended CROSS checklist. Clinicians involved in the first out-of-bed mobilisation in all 14 Scandinavian neuro-ICUs were eligible to participate. The questionnaire was distributed to local contact persons. Respondents were asked about their clinical practice regarding the first out-of-bed mobilisation, and perceived harms and benefits of early mobilisation.

RESULTS

One hundred eighty clinicians (53% nurses, 31% physicians, and 14% therapists) completed the questionnaire. Eighty-one percent indicated that more than half of patients underwent their first out-of-bed mobilisation in the neuro-ICU. More respondents from Denmark than the remaining countries indicated that both physicians, nurses and physiotherapists contributed to the decision on when to mobilise. Intracranial pressure, cerebral perfusion pressure, sedation, presence of vasospasm and arterial blood pressure were the most used safety clinical indicators for deciding about mobilisation. Clinicians stated several positive effects of mobilisation, for example, improved bowel movements, level of consciousness, motor function, and reduced risk of pneumonia, contractures, delirium, and deep vein thrombosis.

CONCLUSIONS

Mobilisation out of bed is frequently performed in patients with severe ABI in Scandinavian neuro-ICUs. The perceived clinical safety indicators for mobilisation were ICP, CPP, level of sedation, presence of vasospasms, and ABP.

Mobilization in Neurocritical Care: Challenges and Opportunities

PURPOSE OF REVIEW

Mobilization in the Neurological Intensive Care Unit (NICU) significantly improves outcomes and functional recovery while preventing immobility-related complications. The heterogeneity of neurologic conditions necessitates tailored, interdisciplinary mobilization strategies. This article reviews recent research on enhancing the feasibility and effectiveness of mobilization interventions in NICU settings.

RECENT FINDINGS

Early mobilization improves functional outcomes, reduces complications like muscle atrophy and pressure ulcers, and can shorten ICU stays. Safe implementation involves individualized protocols and a multidisciplinary team, emphasizing that early mobilization benefits critically ill neurological patients. Development of evidenced-based protocols for interdisciplinary NICU patient mobilization enhances patient outcomes and quality of life. Use of outcome measures can facilitate mobility while preventing complications from immobility. Future research in embracing emerging technologies such as mobilization equipment and virtual/augmented reality will help determine optimal timing as well as dosage of mobility to improve long-term functional outcomes in the unique NICU population.

Cognitive Effects of Transcranial Direct Current Stimulation Plus Robotic Verticalization in Minimally Conscious State

BACKGROUND AND OBJECTIVES

Transcranial direct current stimulation (tDCS) is a non-invasive therapeutic method that modulates cortical excitability and shows promising results for treating disorders of consciousness (DoCs). Robotic verticalization training (RVT) has been shown to enhance motor and cognitive recovery. This study evaluates the effects of an innovative approach combining RVT with tDCS in individuals with DoCs.

METHODS

Twenty-four subjects with DoCs, particularly those with chronic minimally conscious state (MCS) due to vascular or traumatic brain injury, participated in a quasi-randomized study at the Neurorehabilitation Unit, IRCCS Neurolesi (Messina, Italy). Participants were divided into either a control group (CG) receiving RVT alone or an experimental group (EG) receiving combined tDCS and RVT. Both groups underwent treatments five times weekly for four weeks, with tDCS/sham sessions over the dorsolateral prefrontal cortex (DLPFC) lasting 20 min before Erigo training sessions, which lasted 45 min.

RESULTS

The findings indicate that combining tDCS with Erigo® Pro RTT could lead to greater improvements in cognitive functioning and P300 latency compared to the CG.

CONCLUSIONS

These results suggest that the integrated approach of tDCS with RVT could offer significant benefits for patients with MCS, highlighting its potential to enhance cognitive recovery, such as reducing P300 latency.

Guideline on positioning and early mobilisation in the critically ill by an expert panel

A scientific panel was created consisting of 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology delegated from scientific societies together with a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II. The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The panel formulated PICO questions (addressing the population, intervention, comparison or control group as well as the resulting outcomes), conducted a systematic literature review with abstract screening and full-text analysis and created summary tables. This was followed by grading the evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and a risk of bias assessment. The recommendations were finalized according to GRADE and voted using an online Delphi process followed by a final hybrid consensus conference. The German long version of the guideline was approved by the professional associations. For this English version an update of the systematic review was conducted until April 2024 and recommendation adapted based on new evidence in systematic reviews and randomized controlled trials. In total, 46 recommendations were developed and research gaps addressed.

Early mobility and family partnerships in the intensive care unit: A scoping review of reviews

BACKGROUND

Critical illness significantly impacts the well-being of patients and families. Previous studies show that family members are willing to participate in patient care. Involving families in early mobility interventions may contribute to improved recovery and positive outcomes for patients and families.

AIM

In this scoping review, we investigated early mobility interventions for critically ill patients evaluated in randomized controlled trials and the extent to which family engagement in those interventions are reported in the literature.

STUDY DESIGN

In this scoping review of reviews, EMBASE, CINAHL, PubMed and Cochrane Central databases were searched in October 2019 and updated in February 2022. Systematic reviews were included and assessed using A MeaSurement Tool to Assess Systematic Reviews (AMSTAR) 2. Data were synthesized using a narrative approach. PRISMA-ScR guidelines were adhered to for reporting.

RESULTS

Thirty-three reviews were included which described a range of early mobility interventions for critically ill patients; none explicitly mentioned family engagement. Almost half of the reviews were of low or critically low quality. Insufficient detail of early mobility interventions prompted information to be extracted from the primary studies.

CONCLUSIONS

There are a range of early mobility interventions for critically ill patients but few involve families. Given the positive outcomes of family participation, and family willingness to participate in care, there is a need to explore the feasibility and acceptability of family participation in early mobility interventions.

RELEVANCE TO CLINICAL PRACTICE

Family engagement in early mobility interventions for critically ill patients should be encouraged and supported. How to best support family members and clinicians in enacting family involvement in early mobility requires further investigation.

Effects of robotic rehabilitation using the Erigo® device on patients with neurological injury: a systematic review and meta-analysis of randomized clinical trials

OBJECTIVE

To systematically review the effects of robotic rehabilitation with the Erigo® device on patients with neurological injury on safety, spasticity, muscle strength, functionality, gait/balance, and changes in the level of consciousness.

METHODS

MEDLINE, SciELO, EMBASE, The Cochrane Library - CENTRAL and PEDro databases were consulted without the restriction of date and language. Randomized controlled trials that evaluated the robotic rehabilitation and compared it to conventional or placebo therapy, isolated or in association with other therapy, were selected. Studies in which the treatment time was less than 10 sessions were excluded. The risk of bias was assessed with the use of the RoB 2.0 tool.

RESULTS

Nine studies were included, totaling 347 patients. The robotic rehabilitation performed by the Erigo® device proved to be safe for neurological patients. The meta-analysis showed an improvement for spasticity (MD = 0.29; 95% CI = -0.49 to -0.08; I2 = 0%), but there was no significant increase in muscle strength in patients with stroke (MD = 0.25; CI 95% = -0.22 to -0,71; I2 = 0%). Erigo® showed inconclusive effects on functionality, gait/balance and level of consciousness in patients with severe acquired brain injury and vegetative or minimally conscious state. All studies present some concerns for the risk of bias.

CONCLUSION

Erigo® as a robotic rehabilitation strategy is safe for patients with acquired brain injury and appears to reduce spasticity in patients with stroke. The effects on muscle strength, functionality, gait and balance and level of consciousness remain uncertain and the methodological quality of the clinical trials included in this review is limited.

Effectiveness of coma arousal therapy on patients with disorders of consciousness - A systematic review and meta-analysis

BACKGROUND

Disorders of consciousness (DOC) incorporate stages of awareness and arousal. Through coma arousal therapy sensory deprivation experienced by patients with DOC can be mitigated. Nevertheless, consensus concerning its effectiveness on these patients is still fractional.

PURPOSE

This review aims to investigate the effectiveness of coma arousal therapies on patients with DOC.

METHODS

A meta-analysis was performed by searching electronic databases using search terms, the studies investigating the effect of coma arousal therapy in patients with DOC using the Coma Recovery Scale-Revised and Glasgow Coma Scale as outcome measures were included. The risk of bias was assessed, using Cochrane and Joanna Briggs Institute critical appraisal tools. Further, analysis was conducted for the included studies.

RESULTS

Out of 260 studies, 45 trials were reviewed and assessed for bias, with 31 studies included for analysis. The analysis demonstrates a significant difference in pre- and post - sensory stimulation, vagus nerve stimulation, transcranial magnetic stimulation, and transcranial direct current stimulation. Sensory stimulation showed the greatest mean difference of -4.96; 95% CI = -5.76 to - 4.15. The patients who underwent intervention after 3 months of illness showed significant improvement.

CONCLUSION

The result shows that sensory stimulation, transcranial magnetic stimulation, and transcranial direct stimulation can improve behavioral outcomes of patients with DOC, wherein sensory stimulation is found to be more effective.

Improving Neuroplasticity through Robotic Verticalization Training in Patients with Minimally Conscious State: A Retrospective Study

In disorders of consciousness, verticalization is considered an effective type of treatment to improve motor and cognitive recovery. Our purpose is to investigate neurophysiological effects of robotic verticalization training (RVT) in patients with minimally conscious state (MCS). Thirty subjects affected by MCS due to traumatic or vascular brain injury, attending the intensive Neurorehabilitation Unit of the IRCCS Neurolesi (Messina, Italy), were included in this retrospective study. They were equally divided into two groups: the control group (CG) received traditional verticalization with a static bed and the experimental group (EG) received advanced robotic verticalization using the Erigo device. Each patient was evaluated using both clinical scales, including Levels of Cognitive Functioning (LCF) and Functional Independence Measure (FIM), and quantitative EEG pre (T0) and post each treatment (T1). The treatment lasted for eight consecutive weeks, and sessions were held three times a week, in addition to standard neurorehabilitation. In addition to a notable improvement in clinical parameters, such as functional (FIM) (p < 0.01) and cognitive (LCF) (p < 0.01) outcomes, our findings showed a significant modification in alpha and beta bands post-intervention, underscoring the promising effect of the Erigo device to influence neural plasticity and indicating a noteworthy difference between pre-post intervention. This was not observed in the CG. The observed changes in alpha and beta bands underscore the potential of the Erigo device to induce neural plasticity. The device's custom features and programming, tailored to individual patient needs, may contribute to its unique impact on brain responses.

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.

Neuro-orthopaedic assessment and management in patients with prolonged disorders of consciousness: A review

BACKGROUND

Following a severe acquired brain injury, neuro-orthopaedic disorders are commonplace. While these disorders can impact patients' functional recovery and quality of life, little is known regarding the assessment, management and treatment of neuro-orthopaedic disorders in patients with disorders of consciousness (DoC).

OBJECTIVE

To describe neuro-orthopaedic disorders in the context of DoC and provide insights on their management and treatment.

METHODS

A review of the literature was conducted focusing on neuro-orthopaedic disorders in patients with prolonged DoC.

RESULTS

Few studies have investigated the prevalence of spastic paresis in patients with prolonged DoC, which is extremely high, as well as its correlation with pain. Pilot studies exploring the effects of pharmacological treatments and physical therapy show encouraging results yet have limited efficacy. Other neuro-orthopaedic disorders, such as heterotopic ossification, are still poorly investigated.

CONCLUSION

The literature of neuro-orthopaedic disorders in patients with prolonged DoC remains scarce, mainly focusing on spastic paresis. We recommend treating neuro-orthopaedic disorders in their early phases to prevent complications such as pain and improve patients' recovery. Additionally, this approach could enhance patients' ability to behaviourally demonstrate signs of consciousness, especially in the context of covert awareness.

Body-weight support gait training in neurological intensive care: safety, feasibility, and delays before walking with or without suspension

BACKGROUND

Early Mobilization in Intensive Care Units (ICUs) enhances patients' evolution, but has been rarely studied in neurological ICUs. The aim of this study was to assess gait training with body-weight support (BWS) in neuroICU, and to report on its safety, feasibility and on delays before walking with and without BWS.

METHODS

This study was an observational one-year single-center study. Inclusion criteria were adults with a neurological injury requiring mechanical ventilation. Exclusion criteria were early death or ICU transfer. After weaning from ventilation, patients were screened for indications of BWS walking using predefined criteria.

RESULTS

Patients' conditions were mostly brain injuries: 32% subarachnoid hemorrhages, 42% focal strokes, and 12% traumatic brain injuries. Out of 272 admissions, 136 patients were excluded, 78 were eligible, and 33 performed BWS walking. Among non-eligible patients, 36 walked unsuspended upon ventilation weaning, 17 presented too severe impairments. Among the 45 eligible patients who did not receive BWS training, main reasons were workload and weekends (31%), medical barriers (29%), and early ICU discharge (22%). 78 BWS sessions were performed on the 33 beneficiaries (median sessions per patient 2, max 10). Pre-session, most patients had inadequate response to pain, orders, or simple orientation questions. Sitting without support was impossible for 74%. Most pre-post changes in hemodynamic, respiratory, and pain parameters were small, and recovered spontaneously after the session. Eight sessions were interrupted; reasons were pain, fatigue or major imbalance (4), syncope (1), occurrence of stool (2), and battery failure (1). None of these adverse events required medical intervention, patients recovered upon session interruption. Median session duration was 31 min, patients walked on median 17 m. First BWS session occurred on median 3 days after ventilation weaning, and 11 days before patients were able to walk unsuspended.

CONCLUSIONS

Verticalization and walking using a suspension device in patients in neuroICU allows early gait training, despite challenging neurological impairments. It is safe and generally well tolerated.

TRIAL REGISTRATION

ClinicalTrials database (ID: NCT04300491).

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.

[The use of robotic and technical systems for early mobilization of intensive care patients: A scoping review]

The use of robotic and technical systems for early mobilization of intensive care patients: A scoping review Abstract: Background: Intensive care patients are often subjected to immobility for too long. However, when they are mobilized early, positive effects on patient outcomes, such as improvement in physical function, can be demonstrated. One of the reasons for rare mobilization is that too less therapeutic equipment is available. Aims: This paper provides an overview of previous research on early robot- or technology-assisted mobilization of intensive care patients. Which robotic and technical aids are used in studies on early mobilization of adult intensive care patients by nurses or physiotherapists? What effect of early mobilization using robotic and technical systems on patient outcomes are reported in the studies? Methods: A systematic literature search was undertaken within the Databases Medline, Web of Science, CINAHL, Cochrane Library, Embase, IEEE Xplore, Scopus and WTI between May and July 2020 and in January 2022. In addition, a marginal search was performed via GoogleScolar and ResearchGate in the first search run. Results: 27 publications were included (9 RCTs, 7 texts and opinions, 3 cross-sectional studies, 2 case-control studies, 2 literature reviews, 2 case reports, 2 quasi-experimental intervention studies). It is evident that electronic bed-mounted exercise bicycles and tilt tables are the most commonly used assistive devices. There is an inconsistent data situation with regard to different patient outcomes. Conclusion: Further research on the use of technical and robotic early mobilization is, particularly in relation to different study populations, needed. Early mobilization robotics is not yet part of standard care.

Comparator Groups in ICU-Based Studies of Physical Rehabilitation: A Scoping Review of 125 Studies

To characterize comparator groups (CGs) in ICU-based studies of physical rehabilitation (PR), including the type, content, and reporting.

DATA SOURCES

We followed a five-stage scoping review methodology, searching five databases from inception to June 30, 2022. Study selection and data extraction were completed independently, in duplicate.

STUDY SELECTION

We screened studies by title and abstract, then full-text. We included prospective studies with greater than or equal to two arms enrolling mechanically ventilated adults (≥ 18 yr), with any planned PR intervention initiated in the ICU.

DATA EXTRACTION

We conducted a quantitative content analysis of authors' description of CG type and content. We categorized similar CG types (e.g., usual care), classified content into unique activities (e.g., positioning), and summarized these data using counts (proportions). We assessed reporting using Consensus on Exercise Reporting Template (CERT; proportion of reported items/total applicable).

DATA SYNTHESIS

One hundred twenty-five studies were included, representing 127 CGs. PR was planned in 112 CGs (88.2%; 110 studies), representing four types: usual care (n = 81, 63.8%), alternative treatment than usual care (e.g., different from intervention; n = 18, 14.2%), alternative treatment plus usual care (n = 7, 5.5%), and sham (n = 6, 4.7%). Of 112 CGs with planned PR, 90 CGs (88 studies) reported 60 unique activities, most commonly passive range of motion (n = 47, 52.2%). The remaining 22 CGs (19.6%; 22 studies) reported vague descriptions. PR was not planned in 12 CGs (9.5%; 12 studies), and three CGs (2.4%; three studies) reported no details. Studies reported a median (Q1-Q3) of 46.6% (25.0-73.3%) CERT items. Overall, 20.0% of studies reported no detail to understand planned CG activities.

CONCLUSIONS

The most common type of CG was usual care. We identified heterogeneity in planned activities and CERT reporting deficiencies. Our results could help guide the selection, design, and reporting of CGs in future ICU-based PR studies.

Interventions Facilitating Recovery of Consciousness Following Traumatic Brain Injury: A Systematic Review

People who experience disorders of consciousness (DoC) following a severe traumatic brain injury (TBI) have complex rehabilitation needs addressed by occupational therapy. To examine the effectiveness of interventions to improve arousal and awareness of people with DoC following a TBI. For this systematic review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched six databases in collaboration with a research librarian. Twenty-seven studies were included and grouped thematically. Multimodal sensory stimulation, familiar voices telling structured stories, and transcranial direct current stimulation had a moderate level of evidence. Multimodal sensory stimulation had the strongest evidence in support of its use in clinical practice. Occupational therapy practitioners should administer multimodal stimuli frequently as studies reported administering these interventions at least twice daily. Occupational therapy practitioners should incorporate personally relevant, meaningful, salient stimuli into interventions when treating patients with DoC.

Inpatient Physical Therapy in Moderate to Severe Traumatic Brain Injury in in Older Adults: A Scoping Review

BACKGROUND

Around 500/100,000 Canadians experience a traumatic brain injury (TBI) resulting in long-term disabilities and premature death. Physiotherapy is known to positively impact the prognosis of young adults following a TBI.

OBJECTIVE

This is a scoping review that aimed to identify research topics in physiotherapy interventions for seniors after a TBI, describe potential knowledge gaps, and uncover needs for future research.

METHODOLOGY

Ten databases were interrogated (January-March 2022). We included texts published after 2010, in English or French, scientific papers, guidelines, and gray literature sources targeting in-hospital, acute-to-subacute interventions for people aged ≥55 years old with a moderate-to-severe TBI. The outcomes sought were physical/functional capacities, injury severity, and quality of life.

RESULTS

From 1296 articles, 16 were selected. The number of participants from the studies altogether was 248,794. We identified eight retrospectives studies, three clinical trials, and five articles from the gray literature. Articles were classified according to the nature of their analysis and outcomes: (1) interventional studies including physiotherapy (at least 10 types of rehabilitative or preventive interventions were identified); (2) studies evaluating prognostic factors (five factors identified); and (3) recommendations from clinical practical guidelines and other sources (gray literature). Our results provide evidence that physiotherapy is effective in TBI acute rehabilitation for the elderly to prevent complications arising from the primary injury and to improve functional capacities.

CONCLUSION

The heterogeneity of our results does not allow us to infer the effectiveness of one intervention over another. However, we found that the elderly population benefits from physiotherapy interventions as much as adults, but the gap must be filled with higher-quality studies to make definite recommendations.

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.

Effects of Combination of Functional Electric Stimulation and Robotic Leg Movement Using Dynamic Tilt Table on Walking Characteristics in Post-Stroke Patients with Spastic Hemiplegia: A Randomized Crossover-Controlled Trial

BACKGROUND

Spastic hemiplegia causes slow and unstable walking in post-stroke patients. Dynamic tilt table with robotic leg movement (DTTRLM) is safe and effective in improving walking. Functional electric stimulation (FES) improves walking speed in post-stroke patients with spastic hemiplegia. The aim of this study was to determine the effects of combined DTTRLM + FES on walking speed compared with DTTRLM alone.

METHODS

Twenty post-stroke patients were randomly assigned to receive either a single session of stepping + FES treatment or a single session of stepping alone treatment. After a one-week washout period, the same two groups underwent a single session of the other treatment, and the same measurements were taken. We measured walking speed, cadence, and the number of steps in a 10 m walking test (10MWT) and assessed Modified Ashworth Scale (MAS), Fugl-Meyer Assessment (FMA), and range of motion (ROM) before and after the intervention.

RESULTS

Stepping + FES significantly improved walking speed, number of steps, and ankle inversion ROM, compared with stepping alone. Adverse events were not observed in any subject.

CONCLUSIONS

Robotic stepping therapy combined with FES significantly improved 10 m walking speed (10MWS) compared with stepping only in patients with post-stroke and spastic hemiplegia. Further studies are needed to determine the long-term effects of the combination treatment.

Mobility Interventions for Patients With Disorders of Consciousness Following a Traumatic Brain Injury (June 2013-October 2020)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on the effectiveness of mobility interventions to improve arousal and awareness in people with disorders of consciousness following a traumatic brain injury.

Robotic Verticalization plus Music Therapy in Chronic Disorders of Consciousness: Promising Results from a Pilot Study

Background: Music stimulation is considered a valuable form of intervention in disorders of consciousness (DoC); for instance, verticalization may improve motor and cognitive recovery. Our purpose is to investigate the effects of a novel rehabilitative approach combining robotic verticalization training (RVT) with personalized music stimulation in people with DoC. Methods: Sixteen subjects affected by minimally conscious state due to traumatic brain lesions who attended our Intensive Neuro-Rehabilitation Unit were enrolled in this randomized trial. They received either music robotic verticalization (MRV) using the Erigo device plus a personalized music playlist or only RVT without music stimuli. Each treatment was performed 2 times a week for 8 consecutive weeks in addition to standard neurorehabilitation. Results: We found significant improvements in all patients’ outcomes in the experimental group (who received MRV): Coma Recovery Scale-Revised (CRS-R) (p < 0.01), Level of Cognitive Functioning (LCF) (p < 0.02), Functional Independence Measure (FIM) (p < 0.03), Functional Communication Scale (FCS) (p < 0.007), Trunk Control Test (TCT) (p = 0.05). Significant differences between the two groups were also found in the main outcome measure CRS-R (p < 0.01) but not for TCT and FIM. Conclusions: Our study supports the safety and effectiveness of RVT with the Erigo device in chronic MCS, and the achievement of better outcomes when RVT is combined with music stimulation.

The Outcome of Neurorehabilitation Efficacy and Management of Traumatic Brain Injury

For public health professionals, traumatic brain injury (TBI) and its possible protracted repercussions are a significant source of worry. In opposed to patient neurorehabilitation with developed brain abnormalities of different etiologies, neurorehabilitation of affected persons has several distinct features. The clinical repercussions of the various types of TBI injuries will be discussed in detail in this paper. During severe TBI, the medical course frequently follows a familiar first sequence of coma, accompanied by disordered awareness, followed by agitation and forgetfulness, followed by return of function. Clinicians must be aware of common medical issues that might occur throughout the various stages of neurorehabilitation, for example, posttraumatic hydrocephalus, paroxysmal sympathetic hyperactivity and posttraumatic neuroendocrine disorders, at each step of the process. Furthermore, we address problems about the scheduling of various rehabilitation programs as well as the availability of current data for comprehensive rehabilitative neuropsychology techniques.

Use of Robots in Critical Care: Systematic Review

Background

The recent focus on the critical setting, especially with the COVID-19 pandemic, has highlighted the need for minimizing contact-based care and increasing robotic use. Robotics is a rising field in the context of health care, and we sought to evaluate the use of robots in critical care settings.

Objective

Although robotic presence is prevalent in the surgical setting, its role in critical care has not been well established. We aimed to examine the uses and limitations of robots for patients who are critically ill.

Methods

This systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. MEDLINE, Embase, IEEE Xplore, and ACM Library were searched from their inception to December 23, 2021. Included studies involved patients requiring critical care, both in intensive care units or high-dependency units, or settings that required critical care procedures (eg, intubation and cardiopulmonary resuscitation). Randomized trials and observational studies were included.

Results

A total of 33 studies were included. The greatest application of robots in the intensive care unit was in the field of telepresence, whereby robots proved advantageous in providing a reduced response time, earlier intervention, and lower mortality rates. Challenges of telepresence included regulatory and financial barriers. In therapy and stroke rehabilitation, robots achieved superior clinical outcomes safely. Robotic use in patient evaluation and assessment was mainly through ultrasound evaluation, obtaining satisfactory to superior results with the added benefits of remote assessment, time savings, and increased efficiency. Robots in drug dispensing and delivery increased efficiency and generated cost savings. All the robots had technological limitations and hidden costs.

Conclusions

Overall, our results show that robotic use in critical care settings is a beneficial, effective, and well-received intervention that delivers significant benefits to patients, staff, and hospitals. Looking ahead, it is necessary to form strong ethical and legislative frameworks and overcome various regulatory and financial barriers.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42021234162; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=234162

Mobilising patients with severe acquired brain injury in intensive care (MAWERIC) - Protocol for a randomised cross-over trial

INTRODUCTION

In the early phase after severe brain injury, patients are often bedridden in an attempt to control intracranial homeostasis; however, prolonged immobilisation may trigger complications. There is limited knowledge about the physiological effects of mobilisation in this early phase.

OBJECTIVE

To investigate changes in brain tissue oxygen tension when patients are mobilised using a Sara Combilizer® in the early phase after severe brain injury, in a randomised cross-over design.

METHODS

Patients with traumatic brain injury, subarachnoid haemorrhage or intracranial haematoma, will be randomised to early mobilisation or rest (no mobilisation = control) on the first day that the patient is deemed to be fit for mobilisation, and the opposite on the next day. On both days, patients will undergo continuous multimodal monitoring measuring brain tissue oxygen tension (primary outcome), invasive blood pressure, heart rate, middle cerebral artery blood flow velocity by transcranial Doppler ultrasound, intracranial pressure, and microdialysis markers of cerebral oxidative metabolism.

DISCUSSION

Intensive care unit patients with acute brain injury are frequently immobilised in the early phase after the ictus. The optimal timing and intensity of mobilisation is unknown. The present study attempts to establish if early mobilisation is safe with respect to intracranial homeostasis. Protocol version 1.1. Date: 19.02.2022. Ethical registration: H-21002728; approved on August 11, 2021. GDPR registration: P-2021 - 105; approved on February 10, 2021.

CLINICALTRIALS

govidentifier:NCT05038930; approved on September 8, 2021. Electronic case report file: REDCap-database; created on August 13, 2021.

The Association Between Early Versus Late Physical Therapy Initiation and Outcomes of Trauma Patients With and Without Traumatic Brain Injuries

BACKGROUND

There is a lack of literature regarding the most effective timing to initiate physical therapy (PT) among traumatically injured patients. We aim to evaluate the association between early PT/mobilization versus delayed or late PT/mobilization and clinical outcomes of trauma patients.

METHODS

A retrospective cohort analysis of an urban level-I trauma center from 2014 to 2019 was performed. Univariate analyses and multivariable logistic regression were performed with significance defined as P < 0.05.

RESULTS

A total of 11,937 patients were analyzed. Among patients without a traumatic brain injury (TBI), late PT initiation times were associated with 60% lower odds of being discharged home without services (P < 0.05), significantly increased hospital and ICU length of stay (H-LOS, ICU-LOS) (P < 0.05), and significantly higher odds of complications (VTE, pneumonia, pressure ulcers, ARDS) (P < 0.001). Among patients with a TBI, late PT initiation time had 76% lower odds of being discharged home without services (P < 0.05) and significantly longer H-LOS and ICU-LOS (P < 0.05) however did not experience significantly higher odds of complications (P > 0.05).

CONCLUSIONS

Among traumatically injured patients, early PT is associated with decreased odds of complications, shorter H-LOS and ICU-LOS, and a favorable discharge disposition to home without services. Adoption of early PT initiation/mobilization protocols and establishment of prophylactic measures against complications associated with delayed PT is critical to maximize quality of care and trauma patient outcomes. Multi-center prospective studies are needed to ascertain the impact of PT initiation times in greater detail and to minimize trauma patient morbidity.

Survey of Physiotherapy Practice in Ontario Cardiac Surgery Intensive Care Units

Purpose: This article describes current physiotherapy practice for critically ill adult patients requiring prolonged stays in critical care (> 3 d) after complicated cardiac surgery in Ontario. Method: We distributed an electronic, self-administered 52-item survey to 35 critical care physiotherapists who treat adult cardiac surgery patients at 11 cardiac surgical sites. Pilot testing and clinical sensibility testing were conducted beforehand. Participants were sent four email reminders. Results: The response rate was 80% (28/35). The median reported number of cardiac surgeries performed per week was 30 (interquartile range [IQR] 10), with a median number of 14.5 (IQR 4) cardiac surgery beds per site. Typical reported caseloads ranged from 6 to 10 patients per day per therapist, and 93% reported that they had initiated physiotherapy with patients once they were clinically stable in the intensive care unit. Of 28 treatments, range of motion exercises (27; 96.4%), airway clearance techniques (26; 92.9%), and sitting at the edge of the bed (25; 89.3%) were the most common. Intra-aortic balloon pump and extracorporeal membrane oxygenation appeared to limit physiotherapy practice. Use of outcome measures was limited. Conclusions: Physiotherapists provide a variety of interventions to critically ill cardiac surgery patients. Further evaluation of the limited use of outcome measures in the cardiac surgical intensive care unit is warranted.

Limited Mobility to the Bed Reduces the Chances of Discharge and Increases the Chances of Death in the ICU

BACKGROUND

Progressive mobility in the ICU has been recommended; however, the definitions of low, moderate, and high mobility in the ICU still diverge between studies. Therefore, our objective was to classify the mobility of the sample from verticalization and active withdrawal from the bed, and from that, to analyze the chances of discharge, death, and readmission to the ICU.

MATERIALS AND METHODS

This is an observational and retrospective study that consults the medical records of individuals admitted to the ICU of the University Hospital of Sergipe (HU/SE) between August 2017 and August 2018. Mobility level was classified based on the Intensive Care Unit Mobility Scale (IMS).

RESULTS

A total of 121 individuals were included. The mean age was 61.45 ± 16.45, being 53.7% female. Of these, 28 (23.1%) had low mobility, 33 (27.3%) had moderate mobility, and 60 (49.6%) had high mobility. Individuals with low mobility were 45 times more likely to die (OR = 45.3; 95% CI = 3.23-636.3) and 88 times less likely to be discharged from the ICU (OR = 0.22; 95% CI = 0.002-0.30).

CONCLUSION

Those who evolved with low mobility had a higher chance of death and a lower chance of discharge from the ICU. Moderate and high mobility were not associated with the investigated outcomes.

Factors Influencing Functional Recovery during Rehabilitation after Severe Acquired Brain Injuries: A Retrospective Analysis

Severe acquired brain injuries (sABI) represent one of the main causes of disability and limitation in social life participation that need an intensive rehabilitation approach. The purpose of this study was to identify a possible correlation between different supposed conditioning factors and the efficiency of rehabilitation interventions. In this retrospective study, data were processed regarding 44 patients admitted to a neurorehabilitation department after sABI. A significant correlation with the efficiency of the rehabilitation intervention (expressed as the variation of the Barthel score between discharge and admittance in relation to the duration of the rehabilitative hospitalization) was found for both the etiology of the brain injury (p = 0.023), the precocity of the rehabilitation treatment (p = 0.0475), the presence of a tracheal cannula (p = 0.0084) and forms of nutrition other than oral (p < 0.0001). The results of this study suggest that improving the management of the respiratory system, swallowing and nutritional aspects, and favoring an early and personalized rehabilitation treatment, can help to optimize the overall care of patients suffering from sABI, thus allowing a reduction in complications, improvement in functional recovery and ensuring a better management of economic, social and health resources.

Reabilitação robótica em pacientes com AVC: protocolo de ensaio clínico randomizado

RESUMO O objetivo deste estudo foi propor um protocolo de ensaio clínico randomizado para avaliar o efeito da reabilitação robótica sobre a funcionalidade de pacientes com acidente vascular cerebral (AVC) subagudo. Trata-se de um protocolo de um ensaio clínico randomizado que será desenvolvido no hospital e centro de reabilitação do Pavilhão Pereira Filho da Irmandade da Santa Casa de Misericórdia de Porto Alegre (ISCMPA). Quarenta pacientes com AVC, de ambos os sexos, com idades entre 18 e 85 anos e que apresentem hemiparesia ou fraqueza muscular (Medical Research Council - MRC <48 pontos) serão divididos aleatoriamente em grupo controle ou grupo de intervenção. O grupo de intervenção será aquele que realizará reabilitação robótica utilizando equipamento Erigo®, além da fisioterapia convencional, e o grupo controle receberá fisioterapia convencional por meio de exercícios com movimentos semelhantes aos realizados no robô. As intervenções ocorrerão todos os dias na fase hospitalar e, após a alta, três vezes por semana, totalizando aproximadamente 18 sessões. A funcionalidade será considerada o desfecho primário do estudo e será avaliada por meio da escala de Fugl-Meyer. Consideramos como desfechos secundários a força muscular (MRC e teste de repetição máxima), espasticidade (escala de Ashworth modificada), arquitetura do músculo quadríceps e ecogenicidade (ultrassom), mobilidade (teste timed up and go), grau de incapacidade e dependência (escala de Rankin e de medida de independência funcional), qualidade de vida (questionário EQ-5D), repercussões cardiorrespiratórias (monitoramento de sinais vitais), tempo de internação (em dias) e mortalidade (número de óbitos). Os grupos serão avaliados antes das intervenções, após a décima sessão e ao final de seis semanas de tratamento ou 18 sessões.

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.

Improving motor and cognitive recovery following severe traumatic brain injury using advanced emotional audio-video stimulation: Lessons from a case report

RATIONALE

It is estimated that about 6 million people suffer from severe traumatic brain injury (TBI) each year (73 cases per 100,000 people). TBI may affect emotional, sensory-motor, cognitive, and psychological functions with a consequent worsening of both patient and his/her caregiver's quality of life. In recent years, technological innovations allowed the development of new, advanced sensory stimulation systems, such as Neurowave, to further stimulate residual cognitive abilities and, at the same time, evaluate residual cognition.

PATIENT CONCERN

An 69-year-old Italian man entered our neurorehabilitation unit with a diagnosis of minimally conscious state following severe TBI. He breathed spontaneously via tracheostomy and was fed via percutaneous gastrostomy. At the neurological examination, the patient showed severe tetraparesis as he showed fluctuating alertness and responsiveness to external stimuli and opened the eyes without stimulation.

DIAGNOSIS

Patient was affected by subarachnoid hemorrhage and frontotemporal bilateral hematoma, which were surgically treated with decompressive craniotomy and subsequent cranioplasty about 6 months before.

INTERVENTIONS

The patient underwent a neuropsychological and clinical evaluation before (T0) and after a conventional rehabilitation cycle (T1), and after a Neurowave emotional stimulation-supported rehabilitative cycle (T2).

OUTCOMES

Following conventional rehabilitation (T1), the patient achieved a partial improvement in behavioral responsiveness; there was also a mild improvement in the caregiver's distress. Conversely, Neurowave emotional stimulation session determined (at T2) a significant improvement of the patient's behavioral responsiveness, cognition, and in the caregiver's distress. The P300 recording in response to the NES showed a significant change of P300 magnitude and latency.

DISCUSSION

Our data suggest that emotional-integrated sensory stimulation using adequate visual stimuli represents a beneficial, complementary rehabilitative treatment for patients in minimally conscious state following a severe TBI. This may occur because stimuli with emotional salience can provide a reliable motivational resource to stimulate motor and cognitive recovery following severe TBI.

[Physical factors in the rehabilitation of patients after brain injury: a scientometric analysis of evidence-based studies]

OBJECTIVE

Scientometric analysis of evidence-based studies of the physical and rehabilitation medicine (PRM) technologies' effectiveness in the rehabilitation of patients with traumatic brain injury (TBI).

MATERIAL AND METHODS

The search for the material was carried out in electronic databases (PEDro, eLIBRARY, PubMed), as well as databases of systematic reviews (SR) (Cochrane Library) using the keywords: «brain injury», «brain», «physical therapy». RCTs were assessed on the PEDro scale from 1 to 10 points. For the final analysis the results of foreign SRs and RCTs published in the period from January 2014 to December 2019 were selected.

RESULTS

The analysis of studies devoted to the use of therapeutic physical factors in the rehabilitation of patients with TBI from the standpoint of evidence-based medicine is carried out. The basic trends in evidence-based studies on the use of various forms of physical exercise, neuromuscular stimulation, and robot-assisted training in the rehabilitation of patients with TBI are highlighted. PRM technologies have been identified which usage led to positive results in patients with TBI for a number of physiological indicators but the number of evidence-based studies on this topic was insufficient. Based on the scientometric analysis of benign studies the promising directions in the study of the influence of therapeutic physical factors in the rehabilitation of patients with TBI have been identified.

CONCLUSION

The presented data demonstrate the studies' results conducted over the past 5 years on the use of PRM technologies in patients with previous TBI. A significant part of the methods considered in the article is actively used in domestic rehabilitation that reflects the ubiquitous process of integrating information obtained in the course of evidence-based research. In order to improve the quality of rehabilitation care for patients with TBI the practice of analyzing and conducting evidence-based studies on this nosology should be continued.

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.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Early mobilization of 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).

A systematic review of head-up tilt to improve consciousness in people with a prolonged disorder of consciousness

Objective:

This systematic review analysed the evidence for the effect of head-up tilt (passive-standing) on consciousness among persons in prolonged disorders of consciousness.

Data sources:

Articles were identified through primary database searching (Medline, CINAHL, AMED, The Cochrane Library) and post-citation searching (Scopus).

Review methods:

This review followed the PRISMA statement. The search strategy was created to find articles that combined any conceivable passive standing device, any measure of consciousness and disorders of consciousness of any origin. Inclusion criteria were any papers that evaluated the use of head-up tilt in adults in defined disorders of consciousness. Exclusion criteria included active stand studies, paediatric studies and animal studies.

The search was completed independently by two researchers. Data collection and risk of bias assessment was completed using the Downs and Black tool.

Results:

6867 titles were retrieved (last search completed 21/6/20). Ten papers met the inclusion criteria: five examined the effects of a single head-up tilt treatment, and five the effects of head-up tilt regimes. Eighty-seven participants were randomised in three randomised controlled trials. In the remaining preliminary studies or case series, 233 participants were analysed. Quality was low, with only two high-quality studies available. Four studies were suitable for effect size analysis, where medium to large effect sizes were found. The two high-quality studies found head-up tilt had a large effect on consciousness.

Conclusion:

Overall there is some evidence that repeated passive standing on a tilt-table can improve consciousness, but the relevant studies provoke further questions.

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.

Knowledge of physiotherapists working in adult ICU on contraindications to mobilization

Abstract Introduction: Mobilization is an effective therapy to combat the deleterious effects of immobility, but not all patients are in a condition to be moved; thus, knowledge about contraindication criteria is fundamental. Objective: To evaluate the knowledge of physiotherapists working in adult ICUs on contraindications to the mobilization of critical patients. Method: This was a cross-sectional study in which a survey was applied to physiotherapists working in an adult ICU in the city of Recife. Results: Out of the 36 criteria presented, only five were considered contraindication criteria. Clinical parameters were those that obtained higher frequency for not being considered criteria for contraindication, nor were there observed differences in the relation between the time of working in the ICU. Conclusion: Most physiotherapists did not consider the criteria presented as contraindications to mobilization, so that professional training in mobilization practices and the creation of protocols are necessary.

Neurosensory stimulation outdoors enhances cognition recovery in cognitive motor dissociation: A prospective crossover study

BACKGROUND:

Neurosensory stimulation is effective in enhancing the recovery process of severely brain-injured patients with disorders of consciousness. Multisensory environments are found in nature, recognized as beneficial to many medical conditions. Recent advances detected covert cognition in patients behaviorally categorized as un- or minimally responsive; a state described as cognitive motor dissociation (CMD).

OBJECTIVE:

To determine effectiveness of a neurosensory stimulation approach enhanced by outdoor therapy, in the early phases of recovery in patients presenting with CMD.

METHODS:

A prospective non-randomized crossover study was performed. A two-phase neurosensory procedure combined identical individually goal assessed indoor and outdoor protocols. All sessions were video-recorded and observations rated offline. The frequency of volitional behavior was measured using a behavioral grid.

RESULTS:

Fifteen patients participated in this study. The outdoor group patients had statistically significant higher number of intentional behaviors than the indoor group on seven features of the grid. Additionally, for all items assessed, total amount of behaviors in the outdoor condition where higher than those in the indoor condition.

CONCLUSIONS:

Although preliminary, this study provides robust evidence supporting the effectiveness and appropriateness of an outdoor neurosensory intervention in patients with covert cognition, to improve adaptive goal-oriented behavior. This may be a step towards helping to restore functional interactive communication.

Is Robotic Gait Training Feasible in Adults With Disorders of Consciousness?

OBJECTIVE

To investigate the feasibility and safety of robotic-assisted gait training (RAGT) in adults with disorders of consciousness (DoC).

SETTING

Inpatient rehabilitation hospital.

PARTICIPANTS

Four adult male patients with traumatic brain injury and DoC.

DESIGN

Subjects participated in RAGT with body weight support for 5 to 20 minutes, over 1- to 2-week periods.

MAIN MEASURES

Primary measures included vital signs, walking parameters, pain, arousal, and Agitation Behavior Scale scores. Additional data included Modified Ashworth Scale, Coma Recovery Scale-Revised, and Rancho Los Amigos Scale scores.

RESULTS

All participants safely completed at least one session of RAGT with body weight support with safe vital signs and low agitation levels. Two adverse events occurred (increased somnolence and pain due to harness placement), which were not considered severe. All subjects emerged out of DoC at which point research protocol was stopped.

CONCLUSIONS

Findings suggest inpatient-based RAGT may be safe and feasible to consider when developing a therapy plan of care in adults with DoC.

Influence of posture on blink reflex prepulse inhibition induced by somatosensory inputs from upper and lower limbs

BACKGROUND

Prepulse inhibition (PPI) is a neurophysiological phenomenon whereby a weak stimulus modulates the reflex response to a subsequent strong stimulus. Its physiological purpose is to avoid interruption of sensory processing by subsequent disturbing stimuli at the subcortical level, thereby preventing undesired motor reactions. An important hub in the PPI circuit is the pedunculopontine nucleus, which is also involved in the control of posture and sleep/wakefulness.

OBJECTIVE

To study the effect of posture (supine versus standing) on PPI, induced by somatosensory prepulses to either upper or lower limb. PPI was measured as the percentage inhibition of the blink reflex response to electrical supraorbital nerve (SON) stimulation.

METHODS

Sixteen healthy volunteers underwent bilateral blink reflex recordings following SON stimulation either alone (baseline) or preceded by an electrical prepulse to the median nerve (MN) or sural nerve (SN), both in supine and standing. Stimulus intensity was 8 times sensory threshold for SON, and 2 times sensory threshold for MN and SN, respectively. Eight stimuli were applied in each condition.

RESULTS

Baseline blink reflex parameters did not differ significantly between the two postures. Prepulse stimulation to MN and SN caused significant inhibition of R2. In supine but not in standing, R2 was significantly more inhibited by MN than by SN prepulses. In standing, SN stimulation caused significantly more inhibition of R2 than in supine, while the inhibition caused by MN prepulses did not differ significantly between postures.

SIGNIFICANCE

PPI induced by lower limb afferent input may contribute to postural control while standing.

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.

Neurorehabilitation of Traumatic Brain Injury (TBI): A Clinical Review

Traumatic brain injury (TBI) and its potential long-term consequences are of major concern for public health. Neurorehabilitation of affected individuals has some specific characteristics in contrast to neurorehabilitation of patients with acquired brain lesions of other aetiology. This review will deal with the clinical consequences of the distinct lesions of TBI. In severe TBI, clinical course often follows a typical initial sequence of coma; followed by disturbed consciousness; later, post-traumatic agitation and amnesia; and finally, recovery of function occurs. In the different phases of neurorehabilitation, physicians should be aware of typical medical complications such as paroxysmal sympathetic hyperactivity, posttraumatic hydrocephalus, and posttraumatic neuroendocrine dysfunctions. Furthermore, we address questions on timing and on existing evidence for different rehabilitation programmes and for holistic neuropsychological rehabilitation approaches.

Physical rehabilitation interventions in the intensive care unit: a scoping review of 117 studies

BACKGROUND

Physical rehabilitation (PR) interventions in the intensive care unit (ICU) can improve patients' functional outcomes, yet systematic reviews identified discordant effects and poor reporting. We conducted a scoping review to determine the extent of ICU PR interventions and how they were reported and measured.

METHODS

We searched five databases from inception to December 2016 for prospective studies evaluating adult ICU PR interventions. Two independent reviewers screened titles, abstracts, and full texts for inclusion. We assessed completeness of reporting using the Consolidated Standards of Reporting Trials, Strengthening the Reporting of Observational Studies in Epidemiology, or Standards for Quality Improvement Reporting Excellence guidelines, as appropriate. For planned PR interventions, we evaluated reporting with the Consensus on Exercise Reporting Template (CERT) and assessed intervention and control groups separately. We calculated completeness of reporting scores for each study; scores represented the proportion of reported items. We compared reporting between groups using Kruskal-Wallis with Bonferroni corrections and t tests, α = 0.05.

RESULTS

We screened 61,774 unique citations, reviewed 1429 full-text publications, and included 117: 39 randomized trials, 30 case series, 9 two-group comparison, 14 before-after, and 25 cohort. Interventions included neuromuscular electrical stimulation (NMES) (14.5%), passive/active exercises (15.4%), cycling (6.8%), progressive mobility (32.5%), and multicomponent (29.9%). The median (first,third quartiles) study reporting score was 75.9% (62.5, 86.7) with no significant differences between reporting guidelines. Of 87 planned intervention studies, the median CERT score was 55.6%(44.7,75.0); cycling had the highest (85.0%(62.2,93.8)), and NMES and multicomponent the lowest (50.0% (39.5, 70.3) and 50.0% (41.5, 58.8), respectively) scores. Authors reported intervention groups better than controls (p < 0.001).

CONCLUSIONS

We identified important reporting deficiencies in ICU PR interventions, limiting clinical implementation and future trial development.

Physiotherapy in the neurotrauma intensive care unit: A scoping review

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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