The effect of very early mobilisation after stroke on psychological well-being

A Retrospective Analysis of Ischemic Stroke Patients Supports That Very Early Mobilization Within 24 Hours After Intravenous Alteplase Is Safe and Possibly Beneficial

ABSTRACT

BACKGROUND: Stroke care guidelines recommend early mobilization of acute ischemic stroke patients, but there are sparse data regarding early mobilization of stroke patients receiving thrombolytic therapy. We developed the Providence Early Mobility for Stroke (PEMS) protocol to mobilize patients to their highest individual tolerance within 24 hours of stroke admission in 2010, and it has been in continuous use at our primary and comprehensive stroke centers for over a decade. In this study, we evaluated the PEMS protocol in all patients treated with intravenous alteplase without endovascular treatment. METHODS : This retrospective study includes 318 acute ischemic stroke patients treated with alteplase who were admitted to 2 urban stroke centers between January 2013 and December of 2017 and were mobilized with the PEMS protocol within 24 hours of receiving alteplase. Safety of PEMS was assessed by change in National Institutes of Health Stroke Scale at 24 hours by time first mobilized. Using multivariate and logistic regression models, we analyzed time first mobilized and 90-day modified Rankin scale (mRS). RESULTS : Median time first mobilized was 9 hours from administration of alteplase. For every hour delay in mobilization, the odds of being slightly or moderately disabled (mRS, 2-3) at 90 days increased by 7% (adjusted odds ratio, 1.07; P = .004), and the odds of being severely disabled or dead (mRS, 4-6) at 90 days increased by 7% (adjusted odds ratio, 1.07; P = .02). In addition, for every hour delay in mobilization, 24-hour National Institutes of Health Stroke Scale increased by 1.8%. DISCUSSION: Our results support that the PEMS protocol is safe, and possibly beneficial, for acute ischemic stroke patients treated with intravenous alteplase. Our protocol differs from other very early mobility protocols because it does not prescribe a "dose" of activity. Instead, each patient was mobilized to his/her individual highest degree as soon as it was safe to do so.

A checklist-based survey for early mobilization of stroke unit patients in an Italian region

BACKGROUND

Although early mobilization (EM) is recommended by most guidelines in acute stroke patients, there is a paucity of tools to perform a standardized patient risk assessment prior to EM in stroke units (SUs).

OBJECTIVE

This survey aimed at assessing (1) the usefulness of an ad hoc checklist for a standardized approach to EM in SUs and (2) the relationship between EM achieved by this checklist and SU characteristics.

METHODS

This survey was carried out in 10 SUs in Piedmont, Italy. The EM checklist was based on 15 "items", including quantitative/qualitative, clinical and management features.

RESULTS

A total of 250 completed checklists were assessed. EM, defined as out-of-bed activity within 72 h of admission, was reached by 174 patients (69.6%), according to the checklist. There was a statistically significant association between the admission NIHSS score and EM. Hypotension at mobilization was observed in 29/250 patients (11.6%) and was significantly associated with EM. A total of 6 falls (2.4%) were reported. Nurses were most frequently involved in EM, either alone (40.8%) or with another professional.

CONCLUSION

A large percentage of acute stroke patients managed to achieve a safe EM in the SUs that adopted the novel checklist. These results suggest that this checklist may well be a user-friendly, reliable tool to assist SU professionals in deciding whether to mobilize or not, by means of a standardized approach.

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

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

Preventive Approaches for Post-Stroke Depression: Where Do We Stand? A Systematic Review

PURPOSE

Post-stroke depression (PSD) occurs in one-third of stroke survivors, leading to a substantial decrease in quality of life as well as delayed functional and neurological recovery. Early detection of patients at risk and initiation of tailored preventive measures may reduce the medical and socioeconomic burden associated with PSD. We sought to review the current evidence on pharmacological and non-pharmacological prevention of PSD.

MATERIALS AND METHODS

We conducted a systematic review using PubMed/MEDLINE and bibliographies of identified papers following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including randomized controlled studies. Eligible studies were included when performed within 1 year after the index cerebrovascular event. Animal and basic research studies, studies lacking a control group, review papers, and case reports were excluded.

RESULTS

Out of 150 studies screened, 37 met our criteria. Among the strategies identified, administration of antidepressants displayed the most robust evidence for preventing PSD, whereas non-pharmacological interventions such as psychotherapy appear to be the most frequently used approaches to prevent depression after stroke. Research suggests that the efficacy of PSD prevention increases with the duration of preventive treatment. Seven out of 11 studies (63%) that used pharmacological and eight out of 16 (50%) that used non-pharmacological interventions reported a positive preventive effect on PSD.

CONCLUSION

Overall, the current literature on PSD prevention shows heterogeneity, substantiating a need for well-designed randomized controlled trials to test the safety and efficacy of pharmacological as well as non-pharmacological and composite prevention regimens to minimize the risk of PSD in stroke survivors. Integrative strategies combining personalized non-pharmacological interventions such as educational, mental, and physical health support, and pharmacological strategies such as SSRIs may be the most promising approach to prevent PSD.

Older adults experiences with ambulation during a hospital stay: A qualitative study

Older adults often lose their ability to independently ambulate during a hospital stay. Few studies have investigated older adults' experiences with ambulation during hospitalization. The purpose of this study was to understand older adults' perceptions of and experiences with ambulation during a hospital admission. A qualitative study using Inductive Content Analysis was conducted. Community-dwelling older adults (N = 11) were recruited to participant in five focus group meetings each lasting 90 min. All individuals participated in each focus group. Participants described high complexity in deciding whether or not they could ambulate. Six categories were identified: Uncertainty, Restriction Messaging, Non-Welcoming Space, Caring for Nurse and Self, Feeling Isolated, and Presenting Self. This study provides a detailed understanding of older adults' experiences and perceptions of a hospital stay. Findings from this study can serve as a foundation for future interventions to improve older adult patient ambulation during hospitalization.

Assessing adherence to physical activity programs post-stroke at home: A systematic review of randomized controlled trials

BACKGROUND

Physical activity at home provides significant benefits post-stroke. Adherence assessments contribute to objective evaluation of treatment effectiveness across settings.

OBJECTIVES

The aims of this study were to (1) conduct a systematic review with focus on analyzing the reporting quality of RCTs that incorporate home physical activity interventions among people post-stroke, and utilize a physical activity adherence assessment and to: (2) identify, group, and critically appraise physical activity adherence assessments within the identified studies.

METHODS

A literature search for RCTs was conducted. Articles needed to (1) study adult, post-stroke participants, (2) include a physical activity intervention at home, (3) utilize a physical activity adherence assessment, (4) be published in English in a peer reviewed journal. Two independent reviewers assessed the reporting quality of each RCT for conformity to 39 Consolidated Standards of Reporting Trials (CONSORT) items, followed by an evaluation of adherence assessment methods.

RESULTS

Eleven studies met the inclusion criteria and none of them reported all CONSORT items. The median number of "fully reported" items was 7 out of 39. Ten of the 11 RCTs employed the adherence diary as an assessment method. The adherence parameters of frequency and duration were applied with greater frequency than intensity and accuracy. No evidence of an objective method of adherence assessment was found.

CONCLUSIONS

This systematic review revealed suboptimal reporting of RCTs of physical activity interventions. The use of a diary with the post-stroke population at home was common, despite the lack of an objective method of adherence assessment. Stricter compliance to CONSORT guidelines and complementary direct adherence measurement is advised to improve activity adherence research.

Mobilization within 24 hours of new-onset stroke enhances the rate of home discharge at 6-months follow-up: a prospective cohort study

BACKGROUND/OBJECTIVE

Previous research indicates a better improvement of functional independence measure (FIM) at discharge in acute-stroke patients who received physiatrist and registered therapist operating rehabilitation (PROr) within 24 hrs compared with those who received after 24 hrs was reported. The aim of this prospective cohort study was to determine whether PROr provided within 24 hrs for new-onset stroke patients affects home-discharge rate at 6 months later.

METHODS

Acute new-onset stroke patients admitted to our hospital and received PROr (n = 227) and were conducted into 3 categories based on the time until starting PROr; within 24 hrs (very early mobilization; VEM; n = 47), 24-48 hrs (early mobilization; EM; n = 77) and >48 hrs (later mobilization; LM; n = 103). Home-discharge rates as well as changes in FIM, and rates of recurrence and mortality during the 6-month follow-up were assessed.

RESULTS

A total of 139 patients [VEM (n = 32), EM (n = 43), LM (n = 64)] could be followed throughout the 6-month period. The home-discharge rate was ∼80% and significantly higher by ∼20% in VEM than EM. The gains in the motor subscale of FIM at 6 months were significantly higher in VEM than LM, while the mortality and recurrent rates were not significantly different among the categories.

CONCLUSIONS

Starting PROr within 24 hrs of new-onset stroke may help to increase home-discharge rates at 6-month follow-up, simultaneously with a higher FIM. Very early mobilization in our hospital did not increase the risks of recurrence or death.

Transcranial Direct Current Stimulation to Facilitate Lower Limb Recovery Following Stroke: Current Evidence and Future Directions

Stroke remains a global leading cause of disability. Novel treatment approaches are required to alleviate impairment and promote greater functional recovery. One potential candidate is transcranial direct current stimulation (tDCS), which is thought to non-invasively promote neuroplasticity within the human cortex by transiently altering the resting membrane potential of cortical neurons. To date, much work involving tDCS has focused on upper limb recovery following stroke. However, lower limb rehabilitation is important for regaining mobility, balance, and independence and could equally benefit from tDCS. The purpose of this review is to discuss tDCS as a technique to modulate brain activity and promote recovery of lower limb function following stroke. Preliminary evidence from both healthy adults and stroke survivors indicates that tDCS is a promising intervention to support recovery of lower limb function. Studies provide some indication of both behavioral and physiological changes in brain activity following tDCS. However, much work still remains to be performed to demonstrate the clinical potential of this neuromodulatory intervention. Future studies should consider treatment targets based on individual lesion characteristics, stage of recovery (acute vs. chronic), and residual white matter integrity while accounting for known determinants and biomarkers of tDCS response.

Assessment of the Implementation of Critical Pathway in Stroke Patients: A 10-Year Follow-Up Study

Background

The complications after stroke inhibit functional recovery and worsen the prognosis of patients. The implementation of a critical pathway (CP) can facilitate functional recovery after stroke by enabling comprehensive and systematic structured rehabilitation.

Objective

To evaluate the effects of the implementation of CP in stroke patients for 10 years.

Methods

The data were collected from 960 patients who were diagnosed with a stroke at the university hospital emergency room, who were transferred to the rehabilitation center after the acute phase, and who were discharged after undergoing comprehensive rehabilitation. Based on data collected over a period of 10 years, changes in demographic and stroke characteristics, preexisting medical conditions, poststroke complications, and functional states, as well as length of stay (LOS), were evaluated before and after CP implementation. The modified Rankin Scale (mRS) and the Korean version of the Modified Barthel Index (K-MBI) were used to evaluate functional states.

Results

There were no significant differences in demographic and stroke characteristics before and after CP implementation. For those with preexisting medical conditions, there was no significant difference between before and after CP implementation. The majority of the complications were significantly decreased after the implementation of CP. Except for hemorrhagic stroke patients, the Brunnstrom stage in the ischemic and total stroke patients after CP implementation was significantly increased in the upper and lower extremities. The total hospitalization LOS and rehabilitation center hospitalization times were significantly reduced in ischemic and total stroke patients. There was no statistically significant difference in the functional gain of K-MBI and the efficiency of rehabilitation between before and after CP implementation.

Conclusion

The implementation of CP allows for better application of evidence- and guideline-based key interventions and helps to provide early, comprehensive, organized, and more specialized care to stroke patients. Despite limited evidence, CP is still recommended as a means of promoting best practices in hospital care for stroke patients.

The impact of a patient-directed activity program on functional outcomes and activity participation after stroke during inpatient rehabilitation—a randomized controlled trial

Objective:

Individuals post stroke are inactive, even during rehabilitation, contributing to ongoing disability and risk of secondary health conditions. Our aims were to (1) conduct a randomized controlled trial to examine the efficacy of a “Patient-Directed Activity Program” on functional outcomes in people post stroke during inpatient rehabilitation and (2) examine differences three months post inpatient rehabilitation discharge.

Design:

Randomized control trial.

Setting:

Inpatient rehabilitation facility.

Subjects:

Patients admitted to inpatient rehabilitation post stroke.

Interventions:

Patient-Directed Activity Program (PDAP) or control (usual care only). Both groups underwent control (three hours of therapy/day), while PDAP participants were prescribed two additional 30-minute activity sessions/day.

Main measures:

Outcomes (Stroke Rehabilitation Assessment of Movement Measure, Functional Independence Measure, balance, physical activity, Stroke Impact Scale) were collected at admission and discharge from inpatient rehabilitation and three-month follow-up.

Results:

Seventy-three patients (PDAP ( n = 37); control ( n = 36)) were included in the primary analysis. Patients in PDAP completed a total of 23.1 ± 16.5 sessions (10.7 ± 8.5 upper extremity; 12.4 ± 8.6 lower extremity) during inpatient rehabilitation. No differences were observed between groups at discharge in functional measures. PDAP completed significantly more steps/day (PDAP = 657.70 ± 655.82, control = 396.17 ± 419.65; P = 0.022). The Stroke Impact Scale showed significantly better memory and thinking (PDAP = 86.2 ± 11.4, control = 80.8 ± 16.7; P = 0.049), communication (PDAP = 93.6 ± 8.3, control = 89.6 ± 12.4; P = 0.042), mobility (PDAP = 62.2 ± 22.5, control = 53.8 ± 21.8; P = 0.038), and overall recovery from stroke (PDAP = 62.1 ± 19.1, control = 52.2 ± 18.7; P = 0.038) for PDAP compared to control. At three months post discharge, PDAP ( n = 11) completed significantly greater physical activity ( P = 0.014; 3586.5 ± 3468.5 steps/day) compared to control ( n = 10; 1760.9 ± 2346.3 steps/day).

Conclusion:

Functional outcome improvement was comparable between groups; however, PDAP participants completed more steps and perceived greater recovery.

Use of robot technology in passive mobilization of acute hospitalized geriatric medicine patients: a pilot test and feasibility study

Background

Along with an aging population, the field of robot technology in rehabilitation is expanding. As new technologies develop, it is important to test these clinically before implementation. To assess the possibilities of undertaking a future randomized controlled trial (RCT), the aim of this study was to pilot test and investigate the feasibility of a newly developed passive mobilization robot device in geriatric medicine patients.

Methods

We used a robot to perform passive mobilization for all recruited patients while they were lying in bed. Inclusion criteria include the following: ≥ 65 years of age, able to walk before hospitalization, and not capable of walking > 2 m at the first day of hospitalization. Exclusion criteria include the following: known moderate/severe dementia, unstable fractures (back, pelvis, or legs), high intracranial pressure, pressure ulcers/risk of developing pressure ulcers due to fragile skin, positive Confusion and Assessment Method (CAM) score, not able to understand Danish, and medical instability. A mixed-methods approach, including structured interviews for patients and relatives, questionnaires and semi-structured interviews for the staff, and observations in the clinic were used as data collection methods. A 6-week pilot test preceded the feasibility study to test study design, safety, interview guide, and setting, and to become familiar with the robot.

Results

The pilot test included 13 patients, made the staff confident in the use of the robot, and led to the correction of the interview guide. In the feasibility study, 177 patients were screened, 14 patients (four men, nine women) included, and 13 completed the intervention (median [IQR] age 86 [82–92] years). Overall, the robot was easy to use during passive mobilization and fully accepted by patients and relatives. Staff, however, found the robot difficult to maneuver. No adverse events were reported.

Conclusions

Use of robot technology in passive mobilization of older patients was feasible and well accepted by patients, relatives, and staff. Technical and workflow-related issues, as well as the robot not performing active mobilization, affects the launch of a RCT and thereby its implementation in geriatric medicine patients.

Scaling-up implementation in community hospitals: a multisite interrupted time series design of the Mobilization of Vulnerable Elders (MOVE) program in Alberta

Background

As the population ages, older hospitalized patients are at increased risk for hospital-acquired morbidity. The Mobilization of Vulnerable Elders (MOVE) program is an evidence-informed early mobilization intervention that was previously evaluated in Ontario, Canada. The program was effective at improving mobilization rates and decreasing length of stay in academic hospitals. The aim of this study was to scale-up the program and conduct a replication study evaluating the impact of the evidence-informed mobilization intervention on various units in community hospitals within a different Canadian province.

Methods

The MOVE program was tailored to the local context at four community hospitals in Alberta, Canada. The study population was patients aged 65 years and older who were admitted to medicine, surgery, rehabilitation and intensive care units between July 2015 and July 2016. The primary outcome was patient mobilization measured by conducting visual audits twice a week, three times a day. The secondary outcomes included hospital length of stay obtained from hospital administrative data, and perceptions of the intervention assessed through a qualitative assessment. Using an interrupted time series design, the intervention was evaluated over three time periods (pre-intervention, during, and post-intervention).

Results

A total of 3601 patients [mean age 80.1 years (SD = 8.4 years)] were included in the overall analysis. There was a significant increase in mobilization at the end of the intervention period compared to pre-intervention, with 6% more patients out of bed (95% confidence interval (CI) 1, 11; p-value = 0.0173). A decreasing trend in median length of stay was observed, where patients on average stayed an estimated 3.59 fewer days (95%CI -15.06, 7.88) during the intervention compared to pre-intervention period.

Conclusions

MOVE is a low-cost, effective and adaptable intervention that improves mobilization in older hospitalized patients. This intervention has been replicated and scaled up across various units and hospital settings.

Variation in Hospital-Based Rehabilitation Services Among Patients With Ischemic Stroke in the United States

BACKGROUND

Little is known about variation in use of rehabilitation services provided in acute care hospitals for people who have had a stroke.

OBJECTIVE

The objective was to examine patient and hospital sources of variation in acute care rehabilitation services provided for stroke.

DESIGN

This was a retrospective, cohort design.

METHODS

The sample consisted of Medicare fee-for-service beneficiaries with ischemic stroke admitted to acute care hospitals in 2010. Medicare claims data were linked to the Provider of Services file to gather information on hospital characteristics and the American Community Survey for sociodemographic data. Chi-square tests compared patient and hospital characteristics stratified by any rehabilitation use. We used multilevel, multivariable random effect models to identify patient and hospital characteristics associated with the likelihood of receiving any rehabilitation and with the amount of therapy received in minutes.

RESULTS

Among 104,295 patients, 85.2% received rehabilitation (61.5% both physical therapy and occupational therapy; 22.0% physical therapy only; and 1.7% occupational therapy only). Patients received 123 therapy minutes on average (median [SD] = 90.0 [99.2] minutes) during an average length of stay of 4.8 [3.5] days. In multivariable analyses, male sex, dual enrollment in Medicare and Medicaid, prior hospitalization, ICU stay, and feeding tube were associated with lower odds of receiving any rehabilitation services. These same variables were generally associated with fewer minutes of therapy. Patients treated by tissue plasminogen activator, in limited-teaching and nonteaching hospitals, and in hospitals with inpatient rehabilitation units, were more likely to receive more therapy minutes.

LIMITATION

The findings are limited to patients with ischemic stroke.

CONCLUSION

Only 61% of patients with ischemic stroke received both physical therapy and occupational therapy services in the acute setting. We identified considerable variation in the use of rehabilitation services in the acute care setting following a stroke.

Can the effects of the mobilization of vulnerable elders in Ontario (MOVE ON) implementation be replicated in new settings: an interrupted time series design

BACKGROUND

Bed rest for older hospitalized patients places them at risk for hospital-acquired morbidity. We previously evaluated an early mobilization intervention and found it to be effective at improving mobilization rates and decreasing length of stay on internal medicine units. The aim of this study was to conduct a replication study evaluating the impact of the evidence-informed mobilization intervention on surgery, psychiatry, medicine, and cardiology inpatient units.

METHODS

A multi-component early mobilization intervention was tailored to the local context at seven hospitals in Ontario, Canada. The primary outcome was patient mobilization measured by conducting visual audits twice a week, three times a day. Secondary outcomes were hospital length of stay and discharge destination, which were obtained from hospital decision support data. The study population was patients aged 65 years and older who were admitted to surgery, psychiatry, medicine, and cardiology inpatient units between March and August 2014. Using an interrupted time series design, the intervention was evaluated over three time periods-pre-intervention, during, and post-intervention.

RESULTS

A total of 3098 patients [mean age 78.46 years (SD 8.38)] were included in the overall analysis. There was a significant increase in mobility immediately after the intervention period compared to pre-intervention with a slope change of 1.91 (95% confidence interval [CI] 0.74-3.08, P-value = 0.0014). A decreasing trend in median length of stay was observed in the majority of the participating sites. Overall, a median length of stay of 26.24 days (95% CI 23.67-28.80) was observed pre-intervention compared to 23.81 days (95% CI 20.13-27.49) during the intervention and 24.69 days (95% CI 22.43-26.95) post-intervention. The overall decrease in median length of stay was associated with the increase in mobility across the sites.

CONCLUSIONS

MOVE increased mobilization and these results were replicated across surgery, psychiatry, medicine, and cardiology inpatient units.

Very early versus delayed mobilisation after stroke

BACKGROUND

Very early mobilisation (VEM) is performed in some stroke units and recommended in some acute stroke clinical guidelines. However, it is unclear whether very early mobilisation independently improves outcome after stroke.

OBJECTIVES

To determine whether very early mobilisation (started as soon as possible, and no later than 48 hours after onset of symptoms) in people with acute stroke improves recovery (primarily the proportion of independent survivors) compared with usual care.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched 31 July 2017). We also systematically searched 19 electronic databases including; CENTRAL; 2017, Issue 7 in the Cochrane Library (searched July 2017), MEDLINE Ovid (1950 to August 2017), Embase Ovid (1980 to August 2017), CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to August 2017) , PsycINFO Ovid (1806 to August 2017), AMED Ovid (Allied and Complementary Medicine Database), SPORTDiscus EBSCO (1830 to August 2017). We searched relevant ongoing trials and research registers (searched December 2016), the Chinese medical database, Wanfangdata (searched to November 2016), and reference lists, and contacted researchers in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of people with acute stroke, comparing an intervention group that started out-of-bed mobilisation within 48 hours of stroke, and aimed to reduce time-to-first mobilisation, with or without an increase in the amount or frequency (or both) of mobilisation activities, with usual care, where time-to-first mobilisation was commenced later.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, assessed risk of bias, and applied the GRADE approach to assess the quality of the evidence. The primary outcome was death or poor outcome (dependency or institutionalisation) at the end of scheduled follow-up. Secondary outcomes included death, dependency, institutionalisation, activities of daily living (ADL), extended ADL, quality of life, walking ability, complications (e.g. deep vein thrombosis), patient mood, and length of hospital stay. We also analysed outcomes at three-month follow-up.

MAIN RESULTS

We included nine RCTs with 2958 participants; one trial provided most of the information (2104 participants). The median (range) delay to starting mobilisation after stroke onset was 18.5 (13.1 to 43) hours in the VEM group and 33.3 (22.5 to 71.5) hours in the usual care group. The median difference within trials was 12.7 (4 to 45.6) hours. Other differences in intervention varied between trials; in five trials, the VEM group were also reported to have received more time in therapy, or more mobilisation activity.Primary outcome data were available for 2542 of 2618 (97.1%) participants randomized and followed up for a median of three months. VEM probably led to similar or slightly more deaths and participants who had a poor outcome, compared with delayed mobilisation (51% versus 49%; odds ratio (OR) 1.08, 95% confidence interval (CI) 0.92 to 1.26; P = 0.36; 8 trials; moderate-quality evidence). Death occurred in 7% of participants who received delayed mobilisation, and 8.5% of participants who received VEM (OR 1.27, 95% CI 0.95 to 1.70; P = 0.11; 8 trials, 2570 participants; moderate-quality evidence), and the effects on experiencing any complication were unclear (OR 0.88; 95% CI 0.73 to 1.06; P = 0.18; 7 trials, 2778 participants; low-quality evidence). Analysis using outcomes collected only at three-month follow-up did not alter the conclusions.The mean ADL score (measured at end of follow-up, with the 20-point Barthel Index) was higher in those who received VEM compared with the usual care group (mean difference (MD) 1.94, 95% CI 0.75 to 3.13, P = 0.001; 8 trials, 9 comparisons, 2630/2904 participants (90.6%); low-quality evidence), but there was substantial heterogeneity (93%). Effect sizes were smaller for outcomes collected at three-month follow-up, rather than later.The mean length of stay was shorter in those who received VEM compared with the usual care group (MD -1.44, 95% CI -2.28 to -0.60, P = 0.0008; 8 trials, 2532/2618 participants (96.7%); low-quality evidence). Confidence in the answer was limited by the variable definitions of length of stay. The other secondary outcome analyses (institutionalisation, extended activities of daily living, quality of life, walking ability, patient mood) were limited by lack of data.Sensitivity analyses by trial quality: none of the outcome conclusions were altered if we restricted analyses to trials with the lowest risk of bias (based on method of randomization, allocation concealment, completeness of follow-up, and blinding of final assessment), or information about the amount of mobilisation.Sensitivity analysis by intervention characteristics: analyses restricted to trials where the mean VEM time-to-first mobilisation was less than 24 hours, showed an odds of death of 1.35 (95% CI 0.99 to 1.83; P = 0.06; I² = 25%; 5 trials). Analyses restricted to the trials that clearly reported a more prolonged out-of-bed activity showed a similar primary outcome (OR 1.14; 0.96 to 1.35; P = 0.13; I² = 28%; 5 trials), and odds of death (OR 1.27; 0.93 to 1.73; P = 0.13; I² = 0%; 4 trials) to the main analysis.Exploratory network meta-analysis (NMA): we were unable to analyze by the amount of therapy, but low-quality evidence indicated that time-to-first mobilisation at around 24 hours was associated with the lowest odds of death or poor outcome, compared with earlier or later mobilisation.

AUTHORS' CONCLUSIONS

VEM, which usually involved first mobilisation within 24 hours of stroke onset, did not increase the number of people who survived or made a good recovery after their stroke. VEM may have reduced the length of stay in hospital by about one day, but this was based on low-quality evidence. Based on the potential hazards reported in the single largest RCT, the sensitivity analysis of trials commencing mobilisation within 24 hours, and the NMA, there was concern that VEM commencing within 24 hours may carry an increased risk, at least in some people with stroke. Given the uncertainty around these effect estimates, more detailed research is still required.

Feasibility of a postacute structured aerobic exercise intervention following sport concussion in symptomatic adolescents: a randomised controlled study

Objective

The utility of structured exercise for rehabilitation purposes early in the postacute phase (ie, beyond the initial 24–48 hours of advised rest) following sport-related concussion (SRC) remains largely unexplored. This study examined the feasibility of implementing a standardised aerobic exercise (AE) intervention in the postacute stage of SRC recovery in a sample of adolescent students with SRC compared with usual care.

Methods

Symptomatic adolescents with SRC were randomised to one of two groups: Aerobic Exercise (n=8) or Usual Care (n=7). The AE intervention, beginning on day 6 postinjury, comprised eight sessions with progressive increases in intensity and duration on a cycle ergometer. Usual care consisted of rest followed by physician-advised progressions in activity levels in an unsupervised setting. All participants were evaluated by physician at weeks 1, 2, 3 and 4 postconcussion. Outcome measures included: (1) Intervention feasibility: symptom status pre-post exercise sessions and completion of intervention and (2) Clinical recovery: symptom status at weeks 1, 2, 3 and 4 postinjury and medical clearance date.

Results

All participants completed the exercise sessions as part of the AE intervention and symptom exacerbation was not associated with any exercise session. The AE group experienced greater symptom resolution compared with the Usual Care Group across the recovery timeline.

Conclusion

A structured AE protocol appears to be safe and feasible to administer in the postacute stage of SRC recovery in adolescents and should be explored as part of a full Phase III Clinical Trial.

Outcomes of Mobilisation of Vulnerable Elders in Ontario (MOVE ON): a multisite interrupted time series evaluation of an implementation intervention to increase patient mobilisation

Background

older patients admitted to hospitals are at risk for hospital-acquired morbidity related to immobility. The aim of this study was to implement and evaluate an evidence-based intervention targeting staff to promote early mobilisation in older patients admitted to general medical inpatient units.

Methods

the early mobilisation implementation intervention for staff was multi-component and tailored to local context at 14 academic hospitals in Ontario, Canada. The primary outcome was patient mobilisation. Secondary outcomes included length of stay (LOS), discharge destination, falls and functional status. The targeted patients were aged ≥ 65 years and admitted between January 2012 and December 2013. The intervention was evaluated over three time periods-pre-intervention, during and post-intervention using an interrupted time series design.

Results

in total, 12,490 patients (mean age 80.0 years [standard deviation 8.36]) were included in the overall analysis. An increase in mobilisation was observed post-intervention, where significantly more patients were out of bed daily (intercept difference = 10.56%, 95% CI: [4.94, 16.18]; P < 0.001) post-intervention compared to pre-intervention. Hospital median LOS was significantly shorter during the intervention period (intercept difference = -3.45 days, 95% CI: [-6.67,-0.23], P = 0.0356) compared to pre-intervention. It continued to decrease post-intervention with significantly fewer days in hospital (intercept difference= -6.1, 95% CI: [-11,-1.2]; P = 0.015) in the post-intervention period compared to pre-intervention.

Conclusions

this is a large-scale study evaluating an implementation strategy for early mobilisation in older, general medical inpatients. The positive outcome of this simple intervention on an important functional goal of getting more patients out of bed is a striking success for improving care for hospitalised older patients.

Effects of physiatrist and registered therapist operating acute rehabilitation (PROr) in patients with stroke

OBJECTIVE

Clinical evidence suggests that early mobilization of patients with acute stroke improves activity of daily living (ADL). The purpose of this study was to compare the utility of the physiatrist and registered therapist operating acute rehabilitation (PROr) applied early or late after acute stroke.

SUBJECTS AND METHODS

This study was prospective cohort study, assessment design. Patients with acute stroke (n = 227) admitted between June 2014 and April 2015 were divided into three groups based on the time of start of PROr: within 24 hours (VEM, n = 47), 24-48 hours (EM, n = 77), and more than 48 hours (OM, n = 103) from stroke onset. All groups were assessed for the number of deaths during hospitalization, and changes in the Glasgow Coma Scale (GCS), National Institute of Health Stroke Scale (NIHSS), and Functional Independence Measure (FIM) at hospital discharge.

INTERVENTIONS

All patients were assessed by physiatrists, who evaluated the specific needs for rehabilitation, and then referred them to registered physical therapists and occupational therapists to provide early mobilization (longer than one hour per day per patient).

RESULTS

The number of deaths encountered during the PROr period was 13 (out of 227, 5.7%), including 2 (4.3%) in the VEM group. GCS improved significantly during the hospital stay in all three groups, but the improvement on discharge was significantly better in the VEM group compared with the EM and OM groups. FIM improved significantly in the three groups, and the gains in total FIM and motor subscale were significantly greater in the VEM than the other groups.

CONCLUSIONS

PROr seems safe and beneficial rehabilitation to improve ADL in patients with acute stroke.

A systematic review of rehabilitation interventions to prevent and treat depression in post-stroke aphasia

PURPOSE

Stepped psychological care is the delivery of routine assessment and interventions for psychological problems, including depression. The aim of this systematic review was to analyze and synthesize the evidence of rehabilitation interventions to prevent and treat depression in post-stroke aphasia and adapt the best evidence within a stepped psychological care framework.

METHOD

Four databases were systematically searched up to March 2017: Medline, CINAHL, PsycINFO and The Cochrane Library.

RESULTS

Forty-five studies met inclusion and exclusion criteria. Level of evidence, methodological quality and results were assessed. People with aphasia with mild depression may benefit from psychosocial-type treatments (based on 3 level ii studies with small to medium effect sizes). For those without depression, mood may be enhanced through participation in a range of interventions (based on 4 level ii studies; 1 level iii-3 study and 6 level iv studies). It is not clear which interventions may prevent depression in post-stroke aphasia. No evidence was found for the treatment of moderate to severe depression in post-stroke aphasia.

CONCLUSIONS

This study found some interventions that may improve depression outcomes for those with mild depression or without depression in post-stroke aphasia. Future research is needed to address methodological limitations and evaluate and support the translation of stepped psychological care across the continuum. Implications for Rehabilitation Stepped psychological care after stroke is a framework with levels 1 to 4 which can be used to prevent and treat depression for people with aphasia. A range of rehabilitation interventions may be beneficial to mood at level 1 for people without clinically significant depression (e.g., goal setting and achievement, psychosocial support, communication partner training and narrative therapy). People with mild symptoms of depression may benefit from interventions at level 2 (e.g., behavioral therapy, psychosocial support and problem solving). People with moderate to severe symptoms of depression require specialist mental health/behavioral services in collaboration with stroke care at levels 3 and 4 of stepped psychological care.

Design, Analysis, and Optimization of an Acute Stroke Gait Rehabilitation Device

Stroke is one of the leading causes of adult physical disability, and rehabilitation and hospitalization costs for stroke are among the highest for all injuries. Current rehabilitation techniques are labor intensive and time consuming for therapists and difficult to perform effectively. Research suggests that starting rehabilitation during the acute or subacute stage of recovery results in better outcomes than therapy delivered in the chronic stage. To improve the gait rehabilitation process, robot-assisted gait rehabilitation has gained much interest over the past years. However, many robot-assisted rehabilitation devices have limitations; one of which is being bulky and complex to handle. Large and expensive devices that require special training to operate are less attractive to clinics and therapists, and ultimately less likely to be available to patients especially at the early stage of stroke. To address these limitations, this research proposes a new gait rehabilitation device called the linkage design gait trainer (LGT). The device is based on a walking frame design with a simple four-bar linkage “end-effector” mechanism to generate normal gait trajectories during general walking and exercise. The design of the four-bar linkage mechanism was optimized for a particular gait pattern. A prototype of the device was developed and tested. The kinematics of the device itself and gait kinematics with and without assistance from the device were recorded and analyzed using an optical motion capture system. The results show the linkage mechanism is able to guide the leg of the user during over ground walking. There were some differences in the hip (20.5 deg RMS) and knee (14.8 deg RMS) trajectory between the person walking with and without the device assistance. The study demonstrated the concept and feasibility of this novel gait training device.

Access, timing and frequency of very early stroke rehabilitation - insights from the Baden-Wuerttemberg stroke registry

BACKGROUND

While the precise timing and intensity of very early rehabilitation (VER) after stroke onset is still under discussion, its beneficial effect on functional disability is generally accepted. The recently published randomized controlled AVERT trial indicated that patients with severe stroke might be more susceptible to harmful side effects of VER, which we hypothesized is contrary to current clinical practice. We analyzed the Baden-Wuerttemberg stroke registry to gain insight into the application of VER in acute ischemic stroke (IS) and intracerebral hemorrhage (ICH) in clinical practice.

METHODS

99,753 IS patients and 8824 patients with ICH hospitalized from January 2008 to December 2012 were analyzed. Data on the access to physical therapy (PT), occupational therapy (OT), and speech therapy (ST), the time from admission to first contact with a therapist and the average number of therapy sessions during the first 7 days of admission are reported. Multiple logistic regression models adjusted for patient and treatment characteristics were carried out to investigate the influence of VER on clinical outcome.

RESULTS

PT was applied in 90/87% (IS/ICH), OT in 63/57%, and ST in 70/65% of the study population. Therapy was mostly initiated within 24 h (PT 87/82%) or 48 h after admission (OT 91/89% and ST 93/90%). Percentages of patients under therapy and also the average number of therapy sessions were highest in those with a discharge modified Rankin Scale score of 2 to 5 and lowest in patients with complete recovery or death during hospitalization. The outcome analyses were fundamentally hindered due to biases by individual decision making regarding the application and frequency of VER.

CONCLUSIONS

While most patients had access to PT we noticed an undersupply of OT and ST. Only little differences were observed between patients with IS and ICH. The staff decisions for treatment seem to reflect attempts to optimize resources. Patients with either excellent or very unfavorable prognosis were less frequently assigned to VER and, if treated, received a lower average number of therapy sessions. On the contrary, severely disabled patients received VER at high frequency, although potentially harmful according to recent indications from the randomized controlled AVERT trial.

Effectiveness of interventions for adults with psychological or emotional impairment after stroke: an evidence-based review

This evidence-based review was conducted to evaluate the effectiveness of occupational therapy interventions to prevent or mitigate the effects of psychological or emotional impairments after stroke. Thirty-nine journal articles met the inclusion criteria. Six types of interventions were identified that addressed depression, anxiety, or mental health-related quality of life: exercise or movement based, behavioral therapy and stroke education, behavioral therapy only, stroke education only, care support and coordination, and community-based interventions that included occupational therapy. Evidence from well-conducted research supports using problem-solving or motivational interviewing behavioral techniques to address depression. The evidence is inconclusive for using multicomponent exercise programs to combat depression after stroke and for the use of stroke education and care support and coordination interventions to address poststroke anxiety. One study provided support for an intensive multidisciplinary home program in improving depression, anxiety, and health-related quality of life. The implications of the findings for practice, research, and education are discussed.

Mobile Phone-Connected Wearable Motion Sensors to Assess Postoperative Mobilization

Background

Early mobilization after surgery reduces the incidence of a wide range of complications. Wearable motion sensors measure movements over time and transmit this data wirelessly, which has the potential to monitor patient recovery and encourages patients to engage in their own rehabilitation.

Objective

We sought to determine the ability of off-the-shelf activity sensors to remotely monitor patient postoperative mobility.

Methods

Consecutive subjects were recruited under the Department of Neurosurgery at Columbia University. Patients were enrolled during physical therapy sessions. The total number of steps counted by the two blinded researchers was compared to the steps recorded on four activity sensors positioned at different body locations.

Results

A total of 148 motion data points were generated. The start time, end time, and duration of each walking session were accurately recorded by the devices and were remotely available for the researchers to analyze. The sensor accuracy was significantly greater when placed over the ankles than over the hips (P<.001). Our multivariate analysis showed that step length was an independent predictor of sensor accuracy. On linear regression, there was a modest positive correlation between increasing step length and increased ankle sensor accuracy (r=.640, r²=.397) that reached statistical significance on the multivariate model (P=.03). Increased gait speed also correlated with increased ankle sensor accuracy, although less strongly (r=.444, r²=.197). We did not note an effect of unilateral weakness on the accuracy of left- versus right-sided sensors. Accuracy was also affected by several specific measures of a patient’s level of physical assistance, for which we generated a model to mathematically adjust for systematic underestimation as well as disease severity.

Conclusions

We provide one of the first assessments of the accuracy and utility of widely available and wirelessly connected activity sensors in a postoperative patient population. Our results show that activity sensors are able to provide invaluable information about a patient’s mobility status and can transmit this data wirelessly, although there is a systematic underestimation bias in more debilitated patients.

Mobile Phone-Connected Wearable Motion Sensors to Assess Postoperative Mobilization

BACKGROUND

Early mobilization after surgery reduces the incidence of a wide range of complications. Wearable motion sensors measure movements over time and transmit this data wirelessly, which has the potential to monitor patient recovery and encourages patients to engage in their own rehabilitation.

OBJECTIVE

We sought to determine the ability of off-the-shelf activity sensors to remotely monitor patient postoperative mobility.

METHODS

Consecutive subjects were recruited under the Department of Neurosurgery at Columbia University. Patients were enrolled during physical therapy sessions. The total number of steps counted by the two blinded researchers was compared to the steps recorded on four activity sensors positioned at different body locations.

RESULTS

A total of 148 motion data points were generated. The start time, end time, and duration of each walking session were accurately recorded by the devices and were remotely available for the researchers to analyze. The sensor accuracy was significantly greater when placed over the ankles than over the hips (P<.001). Our multivariate analysis showed that step length was an independent predictor of sensor accuracy. On linear regression, there was a modest positive correlation between increasing step length and increased ankle sensor accuracy (r=.640, r(2)=.397) that reached statistical significance on the multivariate model (P=.03). Increased gait speed also correlated with increased ankle sensor accuracy, although less strongly (r=.444, r(2)=.197). We did not note an effect of unilateral weakness on the accuracy of left- versus right-sided sensors. Accuracy was also affected by several specific measures of a patient's level of physical assistance, for which we generated a model to mathematically adjust for systematic underestimation as well as disease severity.

CONCLUSIONS

We provide one of the first assessments of the accuracy and utility of widely available and wirelessly connected activity sensors in a postoperative patient population. Our results show that activity sensors are able to provide invaluable information about a patient's mobility status and can transmit this data wirelessly, although there is a systematic underestimation bias in more debilitated patients.

[The early post-stroke mobilization]

Early mobilization is an important prerequisite for the successful recovery after stroke. However, it is unclear at present how early mobilization should be started after stroke. Three randomized controlled trials were devoted to the comparison of the effectiveness and safety of very early (within the first day after stroke) and early (within two days after stroke) mobilization. The meta-analysis of the results of these studies did not reveal any advantages of very early mobilization over early mobilization. One randomized control study was designed to compare the consequences of mobilization within 3 and 7 days after stroke. It has demonstrated that earlier mobilization is associated with fewer complications and does not exert negative effect on cerebral haemodynamics. A number of observational studies confirmed the positive effect of early mobilization on the outcome of stroke. It is concluded that it may be justified to start mobilization on the second day after stroke provided there are no contraindications to such modality. The practicability of very early mobilization remains to be elucidated.

When Should Physical Rehabilitation Commence after Stroke: A Systematic Review

Background

Knowing when to commence physical rehabilitation after stroke is important to ensure optimal benefit for stroke survivors and efficient health care. The aims of this review were to: determine the effects on mortality, function and complications when physical rehabilitation commences ‘early’ (within seven days of stroke); and describe the effects of early transfer to rehabilitation wards/hospitals when sustained rehabilitation is unavailable in acute stroke units.

Review summary

From 3751 potential articles we included 5 randomized controlled trials and 38 cohort studies. Meta-analysis was performed with 3 randomized controlled trials involving 159 people to investigate the effects of commencing physical rehabilitation within 24 h of stroke compared to 48 h. Commencing physical rehabilitation within 24 h trended towards greater mortality (Mantel-Haenszel odds ratio 2·58; 95% confidence interval 0·98 to 6·79, P = 0·06), with no differences in complications or health outcomes. The cohort studies provided evidence of benefits when physical rehabilitation was commenced on the day of admission ( n = 1), within 3 days of stroke ( n = 3), or ‘sooner rather than later’ (3 of 4 studies). The effect of earlier transfer to rehabilitation was reported in 32 cohort studies. In 23/26 (88%) cohort studies that accounted for age and stroke severity, results favored earlier transfer for improving post-stroke function, with no consensus on timeframes.

Conclusion

In summary, the benefits of commencing physical rehabilitation within 24 h of stroke remain unclear from the current literature. Commencing physical rehabilitation or transferring to rehabilitation services ‘early’ may provide better functional outcomes.

Special considerations for mobilizing patients in the neurointensive care unit

Patients with neurologic illness or injury benefit from early interventions to increase physical activity and mobility, but they also have special needs related to hemodynamic stability and intracranial pressure dynamics. After brain injury, moving paralyzed limbs--even passively--helps promote neural plasticity, "rerouting" signals around the injured area and forming new connections, resulting in improved functional recovery. Neurologic deficits may impede a patient's functional and language abilities, so a mobility program must take into account the need for assistive devices, communication strategies, and additional personnel. Because cerebral autoregulation may be impaired, stability of blood pressure and intracranial pressure must be considered when planning mobility activities. The clinical team must consider the full spectrum of mobility for the neuroscience patient, from having the bed in the chair position for a comatose patient to ambulation of the patient with ventriculostomy whose intracranial pressure will tolerate having drainage clamped for a short period of time. Those involved with mobility need to understand the patient's disease process, the implications of increasing activity levels, and the monitoring required during activity.

Evaluation of a multisite educational intervention to improve mobilization of older patients in hospital: protocol for mobilization of vulnerable elders in Ontario (MOVE ON)

Background

Functional decline is a common adverse outcome of hospitalization in older people. Often, this decline is not related to the illness that precipitated admission, but to the process of care delivered in hospital. The association between immobility and adverse consequences is well established, yet older inpatients spend significant amounts of time supine in bed. We aim to implement and evaluate the impact of an evidence-based strategy to promote early mobilization and prevent functional decline in older patients admitted to university-affiliated acute care hospitals in Ontario, Canada. We will implement a multi-component educational intervention to support a change in practice to enhance mobilization of older patients.

Methods/design

Implementation of our early mobilization strategy is guided by the Knowledge to Action Cycle. Through focus groups with frontline staff, we will identify barriers and facilitators to early mobilization. We will tailor the intervention at each site to the identified barriers and facilitators, focusing on the following key messages: to complete a mobility assessment and care plan within 24 hours of the decision to admit patients aged 65 years and older; to achieve mobilization at least 3 times per day; and, to ensure that mobilization is scaled and progressive. The primary outcome, number of patients observed out of bed, will be documented three times per day (in the morning, at lunch and in the afternoon), two days each week. This data collection will occur over 3 phases: pre-implementation (10 weeks), implementation (8 weeks), and post-implementation (20 weeks).

Discussion

This is the first large, multisite study to evaluate the impact of a multi-component knowledge translation strategy on rates of mobilization of older patients in hospital. Our implementation is framed by the Knowledge to Action Cycle, and the intervention is being adapted to the local context. These unique features render our intervention approach more generalizable to multiple practice settings. Contextualization of the intervention has also facilitated engagement of participants from multiple hospitals. Upon completion of this study, we will better understand the barriers and facilitators to implementing an early mobilization strategy across a spectrum of hospitals, as well as the impact of a mobilization strategy.

Necessary and sufficient causes of participation post-stroke: practical and philosophical perspectives

INTRODUCTION

Participation, a construct within the disability/functioning framework, is evaluated on a person's involvement in life situations including family, community, work, social, and civic life. In the context of recovering from a major health event, participation is a treatment goal and it is known to correlate with the quality of life.

OBJECTIVE

The purpose of this study is to track the dynamics of participation post-stroke in relationship to the dynamics of walking capacity, social support, and mood.

METHODS

An inception cohort was followed over the first post-stroke year. Group-based trajectory analysis, a form of latent class analysis, was used to identify distinctive groups of individuals with similar trajectories. Dual trajectories were used to estimate concordance between participation trajectory and trajectories for each of the three constructs under study.

RESULTS

From the sample of 102 persons (mean age 70), four trajectories of participation were identified, two of which were qualified as excellent and very good, and two qualified as fair and poor. All those with excellent walking showed excellent participation. However, people with excellent (and very good) community participation had a range of walking capacities. Most (82%) people with normal mood showed excellent participation. People with good mood but not meeting norms for age showed the complete range of participation trajectories from excellent to poor. The higher proportion of people with excellent or good social support (57%) showed excellent participation.

CONCLUSION

Two treatable component causes of participation, walking capacity and mood, were identified; of these, only excellent walking capacity could be considered a sufficient cause.

Biopsychosocial aspects of atypical odontalgia

Background. A few studies have found somatosensory abnormalities in atypical odontalgia (AO) patients. The aim of the study is to explore the presence of specific abnormalities in facial pain patients that can be considered as psychophysical factors predisposing to AO. Materials and Methods. The AO subjects (n = 18) have been compared to pain-free (n = 14), trigeminal neuralgia (n = 16), migraine (n = 17), and temporomandibular disorder (n = 14). The neurometer current perception threshold (CPT) was used to investigate somatosensory perception. Structured clinical interviews based on the DSM-IV axis I and DSM III-R axis II criteria for psychiatric disorders and self-assessment questionnaires were used to evaluate psychopathology and aggressive behavior among subjects. Results. Subjects with AO showed a lower Aβ, Aδ, and C trigeminal fiber pain perception threshold when compared to a pain-free control group. Resentment was determined to be inversely related to Aβ (rho: 0.62, P < 0.05), Aδ (rho: 0.53, P < 0.05) and C fibers (rho: 0.54, P < 0.05), and depression was inversely related with C fiber (rho: 0.52, P < 0.05) perception threshold only in AO subjects. Conclusion. High levels of depression and resentment can be considered predictive psychophysical factors for the development of AO after dental extraction.

Safety and feasibility of an early mobilization program for patients with aneurysmal subarachnoid hemorrhage

BACKGROUND

Survivors of aneurysmal subarachnoid hemorrhage (SAH) are faced with a complicated recovery, which typically includes surgery, prolonged monitoring in the intensive care unit, and treatment focusing on the prevention of complications.

OBJECTIVE

The purpose of this study was to determine the safety and feasibility of an early mobilization program for patients with aneurysmal SAH.

DESIGN

This study was a retrospective analysis.

METHODS

Twenty-five patients received early mobilization by a physical therapist or an occupational therapist, or both, which focused on functional training and therapeutic exercise in more progressively upright positions. Participation criteria focused on neurologic and physiologic stability prior to the initiation of early mobilization program sessions.

RESULTS

Patients met the criteria for participation in 86.1% of the early mobilization program sessions attempted. Patients did not meet criteria for the following reasons: Lindegaard ratio >3.0 or middle cerebral artery (MCA) mean flow velocity (MFV) >120 cm/s (8.1%), mean arterial pressure (MAP) <80 mm Hg (1.8%), intracranial pressure (ICP) >15 mm Hg (1.8%), unable to open eyes in response to voice (0.9%), respiratory rate >40 breaths/min (0.6%), MAP >110 mm Hg (0.3%), and heart rate <40 bpm (0.3%). Adverse events occurred in 5.9% of early mobilization program sessions for the following reasons: MAP <70 mm Hg (3.1%) or >120 mm Hg (2.4%) and heart rate >130 bpm (0.3%). The 30-day mortality rate for all patients was 0%. Participation in the early mobilization program began a mean of 3.2 days (SD=1.3) after aneurysmal SAH, and patients received an average of 11.4 sessions (SD=4.3). Patients required a mean of 5.4 days (SD=4.2) to participate in out-of-bed activity and a mean of 10.7 days (SD=6.2) to walk ≥15.24 m (50 ft).

CONCLUSIONS

The results of this study suggest that an early mobilization program for patients with aneurysmal SAH is safe and feasible.

The influence of resistance exercise training on the levels of anxiety in ischemic stroke

The aim of this pilot study was to analyze the effect of a strength training program on indicators of trait and state anxiety in patients with ischemic stroke. The subjects were divided into two groups: experimental group (EG) consisting of 11 subjects aged 51.7 ± 8.0 years and a control group (CG) with 13 subjects aged 52.5 ± 7.7 years. EG underwent 12 weeks of strength training, with a frequency of three times a week. For data collection, a State-Trait Anxiety Inventory (STAI) was used. Significant differences were found between pre- and posttest in EG for trait anxiety (43.2 ± 12.5 pretest 39.9 ± 7.3 posttest) and state anxiety (46.9 ± 7.6 pretest 44.9 ± 7.7 posttest) with no differences in CG for trait anxiety (42.9 ± 12.2 pretest 42.6 ± 12.1 posttest) and state anxiety (47.4 ± 8.1 pretest 47.5 ± 8.0 posttest). In the evaluation between the groups, significant differences were found for all indicators of trait anxiety (39.9 ± 7.3 EG; 42.6 ± 12.1 CG) and state anxiety (44.9 ± 7.7 EG; 47.5 ± 8.0 CG). This pilot study indicates that strength training may provide an improvement in trait and state anxiety more than one year after stroke.

Design and evaluation of NEUROBike: a neurorehabilitative platform for bedridden post-stroke patients

Over the past decades, a large number of robotic platforms have been developed which provide rehabilitative treatments aimed at recovering walking abilities in post-stroke patients. Unfortunately, they do not significantly influence patients' performance after three months from the accident. One of the main reasons underlying this result seems to be related to the time of intervention. Specifically, although experimental evidences suggest that early (i.e., first days after the injury) and intense neuro-rehabilitative treatments can significantly favor the functional recovery of post-stroke patients, robots require patients to be verticalized. Consequently, this does not allow them to be treated immediately after the trauma. This paper introduces a new robotic platform, named NEUROBike, designed to provide neuro-rehabilitative treatments to bedridden patients. It was designed to provide an early and well-addressed rehabilitation therapy, in terms of kinesiology, efforts, and fatigue, accounting for exercises functionally related to daily motor tasks. For this purpose, kinematic models of leg-joint angular excursions during both walking and sit-to-stand were developed and implemented in control algorithms leading both passive and active exercises. Finally, a set of pilot tests was carried out to evaluate the performance of the robotic platform on healthy subjects.

A prospective, randomized, single-blinded trial on the effect of early rehabilitation on daily activities and motor function of patients with hemorrhagic stroke

To investigate whether early rehabilitation has a positive impact on the recovery of the activities of daily living and motor function after intracerebral hemorrhagic stroke, 364 patients with hemorrhagic stroke were selected and randomly divided into a rehabilitation group and a control group. The rehabilitation group underwent a standardized, three-stage rehabilitation program. The control group was treated with standard hospital ward, internal medical intervention. The simplified Fugl-Myere assessment scale (FMA) and Modified Barthel Index (MBI) were administered at various time points. The magnitude of improvement was significantly higher in the rehabilitation group than in the control group for both the FMA (p<0.05) and MBI scores (p<0.05). The greatest improvement was observed in the first month post-stroke. Thus, our study shows that early rehabilitation can significantly improve the daily activities and motor functions of patients with stroke.

Does evidence really matter? Professionals' opinions on the practice of early mobilization after stroke

INTRODUCTION

Early mobilization after stroke may be important for a good outcome and it is currently recommended in a range of international guidelines. The evidence base, however, is limited and clear definitions of what constitutes early mobilization are lacking.

AIMS

To explore stroke care professionals' opinions about (1) when after stroke, first mobilization should take place, (2) whether early mobilization may affect patients' final outcome, and (3) what level of evidence they require to be convinced that early mobilization is beneficial.

METHODS

A nine-item questionnaire was used to interview stroke care professionals during a conference in Sydney, Australia.

RESULTS

Among 202 professionals interviewed, 40% were in favor of mobilizing both ischemic and hemorrhagic stroke patients within 24 hours of stroke onset. There was no clear agreement about the optimal time point beyond 24 hours. Most professionals thought that patients' final motor outcome (76%), cognitive outcome (57%), and risk of depression (75%) depends on being mobilized early. Only 19% required a large randomized controlled trial or a systematic review to be convinced of benefit.

CONCLUSION

The spread in opinion reflects the absence of clear guidelines and knowledge in this important area of stroke recovery and rehabilitation, which suggests further research is required.

Prevention of Deep Vein Thrombosis and Pulmonary Embolism in Patients With Stroke

Venous thromboembolism (VTE), encompassing deep venous thrombosis and pulmonary embolism, is a potentially fatal but preventable complication of stroke. Reported rates of VTE after stroke have decreased over the last four decades, possibly due to the implementation of stroke units, early mobilization and hydration, and increased early use of antiplatelets. Additional means of thromboprophylaxis in stroke include mechanical methods (ie, compression stockings) to prevent venous stasis and medical therapy including antiplatelets, heparins, and heparinoids. Risk of VTE must be balanced by potential risk of hemorrhagic complications from pharmacotherapy. Unfractionated heparin, low-molecular-weight heparin (LMWH), and danaparoid are acceptable options for chemoprophylaxis though none have shown superior efficacy for VTE prevention without an associated increase in major hemorrhage. The efficacy and timing of pharmacological thromboprophylaxis in hemorrhagic stroke are not well defined. Graduated compression stockings are associated with an increased rate of adverse events and are not recommended and intermittent pneumatic compression stockings require further investigation.

Enhancing physical activity and brain reorganization after stroke

It is becoming increasingly clear that, if reorganization of brain function is to be optimal after stroke, there needs to be a reorganisation of the methods used in physical rehabilitation and the time spent in specific task practice, strength and endurance training, and aerobic exercise. Frequency and intensity of rehabilitation need to be increased so that patients can gain the energy levels and vigour necessary for participation in physical activity both during rehabilitation and after discharge. It is evident that many patients are discharged from inpatient rehabilitation severely deconditioned, meaning that their energy levels are too low for active participation in daily life. Physicians, therapists, and nursing staff responsible for rehabilitation practice should address this issue not only during inpatient rehabilitation but also after discharge by promoting and supporting community-based exercise opportunities. During inpatient rehabilitation, group sessions should be frequent and need to include specific aerobic training. Physiotherapy must take advantage of the training aids available, including exercise equipment such as treadmills, and of new developments in computerised feedback systems, robotics, and electromechanical trainers. For illustrative purposes, this paper focuses on the role of physiotherapists, but the necessary changes in practice and in attitude will require cooperation from many others.