>> Mona: Hello, my name is Mona Bahouth,
I'm a stroke neurologist and the medical director
of the brain rescue unit at the Johns Hopkins hospital.
In this series,
we have been focusing on concepts
in early stroke recovery care.
In the first module,
we discussed several physiologic concepts
and early complications that are relevant
to early post-stroke recovery.
In this session,
we will now apply that information
as we conceptualize the incorporation of that information
into early activity after stroke.
Our session will include three parts first,
we'll discuss early stroke recovery
challenges and opportunities.
Second we'll review some literature
that guide our principles in the early recovery period.
And finally, we will summarize some strategies
for safe activity in the early stroke recovery period.
In the prior sessions,
we focused on optimizing physiology
and preventing complications,
we will now apply that to the concept
of promoting post-stroke activity.
And while we know that activity is important
for stroke patients to recover, it is easier said than done.
First, there is a limited window of opportunity
for brain repair after stroke.
Therefore, what we do in the first weeks
and months are particularly important especially
for motor recovery.
Secondly, activity and movement are essential
to recover from stroke,
but stroke itself leads to paralysis
and cognitive disturbances that make it difficult
for the patient to engage in complex therapies.
And finally, bedrest leads to additional complications
that can interfere with recovery activities.
Both in the published literature and recent scans
of comprehensive stroke centers still demonstrate
that hospitalized stroke patients spend a majority
of time in bed
and those with intracerebral hemorrhage
may be particularly at risk.
And we know that bedrest is bad,
I don't have to tell this group
that there are many complications of immobility.
And as we look at this diagram,
we're reminded that those complications really affect the
human body from head to toe.
Specific to stroke patients medical complications,
such as deep vein thrombosis, pneumonia,
skin breakdown, constipation, a propensity for delirium
and muscle deconditioning are all particularly concerning.
And as you may remember from the first module complications
that occur in the early stroke repair recovery period have
longterm impact on functional outcome after stroke.
And while avoiding
these complications are critically important
in the early period after stroke,
we also have to set our sights
on getting the right activity delivered to the patient
in the early period after stroke.
Brain repair is a limited window of opportunity,
this is the period when the brain has its best chance
of recovering to its most optimal functional status.
And we can see from this graphic that,
that critical period for rehabilitation occurs
on the order of days
and weeks after stroke ending perhaps up to three
to four weeks after stroke itself.
This is the period of time when there is upregulation
of growth promoting factors
that may propel a person's brain recovery forward,
offering them the best functional recovery
after the stroke themselves.
Therefore merging these concepts together,
guidelines recommend that early rehabilitation
for hospitalized stroke patients is a priority,
and it is recommended
that stroke survivors receive rehabilitation at intensity
that's commensurate
with their anticipated benefit and tolerance.
That way we avoid the consequences
of bedrest while optimizing movements
that will enhance recovery during a peak period
of critical gains.
But implementing these guidelines may not be
as easy as it sounded.
In this slide,
I summarized several early studies
that focused on very early mobilization after stroke.
You can see that a early trial by Bernhardt and colleagues
in 2008 suggested that early mobilization,
if delivered at 18 hours after stroke
versus 31 hours suggested a possible improvement
in functional outcome using the modified Rankin score.
However several other studies, observational studies
and small cohorts after
that suggested no significant difference
in those intervention groups.
In 2015 however, a large multi-center prospective study
was released and this time suggested
that very early mobilization after stroke resulted
in worst functional outcome.
Now let's dig into that a bit more, the avert trial
a very early rehabilitation trial incorporated strategies
to initiate active mobilization within 24 hours
from stroke onset in the intervention group.
Intervention group had guided tasks, specific activities
for each session.
If the patient was in a low arousal group
or fairly dependent,
their section goals may focus on active sitting
with assistance for a short duration
between 10 and 30 minutes.
If a patient were higher functioning
at a level four their session may target standing
and walking and the duration goal was basically dictated
by the patient themselves
with a minimum duration of session of 10 minutes.
In this study,
we know that passive sitting
or resting in the chair was not considered
a very early mobilization activity.
Now the results of these 2100 patients enrolled
in this multi site study suggested
that patients had a reduced odds
of good functional outcome at three months defined
as a modified Rankin score of zero to two.
And you can see that the adjusted odds ratio adjusted
for stroke severity and age suggested a worsened outcome
in the intervention group.
One critique of this well-executed multicenter study was
that the time to first mobilization was clinically similar
between the intervention and control group.
In intervention group, time to first mobilization
from stroke symptom onset was 18 hours compared to 22 hours
in the usual care group.
And while this is a statistically significant difference,
some question whether the difference has clinical relevance.
Therefore the authors went on
to conduct a dose response analysis
and looking at the entire cohort,
they summarize that the time
to first mobilization was 20 hours in terms of the dose
of the intervention patients received on average five out
of bed sessions per day,
this included 18 minutes of out of bed sessions per day
when combined and the total duration of out of bed sessions
over the entire intervention period was 120 minutes.
They then went on to perform a cart analysis to see
if there were any inflection points
that could give us any insightful information.
The complex figure on the left is not intended to be read,
but can be found in their publication in 2016.
And you can see here that the basic points are summarized
in the table next to that flow diagram.
In essence, they divided by three cohorts of age,
age less than 76 years, age between 76 and 86 years
or greater than 86 years old.
We are cautioned that patients
above age 86 did not achieve favorable outcome
in the intervention group.
And therefore we should use caution
when considering very early mobilization of
that group within 24 hours of stroke onset.
However, there were groups who benefited
from very early mobilization
within 24 hours of stroke onset.
If you were under age 76,
70% achieved a favorable outcome defined
as modified Rankin score of zero to two.
And this was under the condition of a relatively small
to medium sized stroke with NIH stroke scale score
of less than or equal to 7.5.
In the 76 to 86 year old group,
58% of patients received a favorable outcome,
if they were enrolled with a low NIH score of less than 4.5
and when they were exposed to frequent short sessions.
Now those short sessions were on the order
of 13 minutes or less.
Therefore there is some information
from this large multicenter trial
that could guide our practice moving forward
when considering a safe, very early mobilization.
These results inform our guidelines
in the early stroke period
and they currently state
that high dose, very early mobilization within 24 hours
of stroke onset may reduce the odds of favorable outcome
at three months and is therefore not recommended.
However, there are no data that guide what
to do after the 24 hour period
or for those patients in which the cart analysis suggested
that even earlier mobilization may benefit the patient.
Therefore to plan our way forward,
we revert back to the physiological principles discussed
in the first module.
As you may recall, disrupted autoregulation
as well as disruption
of the blood brain barrier are two main concepts
that regulate our decisions
in the early stroke recovery period.
But this slide reminds us
that there are several other complexities to consider
as we promote activity for the stroke patient
in their early recovery period.
In this table,
we list several common issues, the potential risks
to the patient related to those issues
and several considerations as you design an activity program
that may benefit your patients.
For example, hemiplegia is common after stroke,
which may place the patient and the staff caring
for that patient at risk for injury.
Therefore in our care delivery models,
we must consider the correct number
of staff needed for a safe movement of patients,
as well as which supportive
and targeted equipment our stroke centers might need
to accomplish early activity and safely
for these patients with hemiplegia.
The next line items reminds us
about blood pressure ability.
As we know, blood pressures may be quite variable
in the early stroke recovery period,
which could lead to stroke extension
since autoregulation is impaired.
Therefore our stroke center care must focus
on monitoring patient for signs of alteration
in cerebral perfusion and planning activities
that help promote cerebral perfusion at a time
that the brain may be vulnerable.
Another example is post-stroke fatigue,
which is common and up to 80% of patients post-stroke.
This may affect a patient's ability to engage with therapy,
and therefore they may not be able
to gain the optimum output of the therapy sessions
if they're too fatigued to participate.
So in planning a program for early activity after stroke,
you need to consider a periods of brain restoration
that are short but balanced with rest periods
within the context of the day
and the other areas are listed here for your consideration.
So we consider that the solutions
to promote early activity after a stroke are several fold.
First, any activity algorithms must be titrated
to the patient's needs
and these should be regulated by protocols.
Second, we need to bring the right tools
to support the patient in a progressive early activity plan.
We need to find ways to motivate the patient toward
their therapies and to engage in them for the duration
that may benefit them to the highest extent.
We need to monitor the therapies closely
and the patient's response to those therapies,
and we need to be agile to modify those therapies based on
that patient's physiologic response.
Here, I provide for you our activity
and mobility algorithm implemented
in the intensive care unit at the Johns Hopkins hospital.
It summarizes the concept
that all patients should be included
in an activity progression plan
and this progressive plan should really take
into account the patient's tolerance
of each level of activity.
This activity algorithm is implemented by both therapists
and nursing staff to assure
that 24 hours a day, the patient is advancing
in terms of their activity, that they are able to tolerate
and progress to the next step forward.
We demonstrated the impact of the implementation
of such an algorithm in a cohort of patients
with intracerebral hemorrhage, who are admitted
to the intensive care unit.
Prior to the study,
we identified that patients
with intracerebral hemorrhage were maintained on bedrest
for prolonged periods of time.
After the implementation of the algorithm,
we could see that patient's odds
of mobilization increased over time,
but most importantly the number of time
that patients were mobilized while hospitalized
in the intensive care unit went up significantly.
All the while this did not change the amount
of resource required in terms of the number
of therapists since this algorithm was accomplished
by both therapists and bedside nursing staff.
Implementing a progressive activity algorithm
also requires the use of supportive equipment,
the pieces of equipment that are most useful to patients
with stroke in the early recovery period focus
on concepts, such as progressive verticalization,
increased activity and endurance training.
All of these devices can be used on a broad range
of patients from patients who are comatose
or have decreased level of responsiveness all the way up
to patients who are engaged
and highly active during their session.
We have demonstrated in several observational studies
that use of these devices are both safe
and meaningful towards those stroke patients recovery.
And this progressive activity algorithm was even safe
in our sickest patients hospitalized
in the neuro critical care unit
at the Johns Hopkins hospital.
In this group of patients placed
on progressive cycle ergometry,
you can see here that both hemodynamic
and intracranial pressures did not change
during the pre-post cycling measurement periods suggesting
that cycle ergometry is safe even for patients who are prone
to elevated intercranial pressure.
In the bottom graph,
you can see that in the subgroup of patients
with external ventricular devices also demonstrated
no significant change while exercising
in the intensive care unit, using cycle ergometer
as a support tool.
This is important to recognize
as many times activity progression is halted
when the patient is sick with issues
of intercranial pressure or hemodynamic status issues.
Another critical element
in our progressive activity algorithm is incorporation
of upper extremity activities.
Very commonly in the hospital setting,
the upper extremity is avoided in terms of exercise
as the focus is more on safe ambulation
and walking for the progression of the patient towards home.
We have found however that patients both tolerate
and enjoy use of the upper extremity cycle ergometer
to use during times
when they are inactive and sitting in a chair
as a part of their activity planning.
Listed here is the algorithm
that we use to adapt this device for critically ill patients
with neurologic illness.
And it is safe to perform upper extremity cycling
in even the sickest cohort of patients.
In this study, we looked for safety issues
when incorporating the upper extremity cycle ergometer
algorithm for our patient population.
On this graph,
we demonstrate that there was no change
in intercranial pressure in the cohort of patients
that had external ventricular device
when using the upper extremity cycling patterns.
This suggests that we do not have any issues
with line dislodgement or patient intolerance even
when they are sick in the hospital or intensive care unit.
As we discussed previously many
of our population have had limited experience
with exercise prior to their stroke,
or maybe under motivated to participate
in their therapies once the stroke has occurred.
Therefore we have taken to the approach of gamification
of our early stroke care in order to motivate patients
and encourage them towards progressive activity.
In this study,
we enrolled several patients into an algorithm
that was generated by a multidisciplinary team
to choose the right game,
to encourage activity to patients
with several domains of post-stroke injury.
As you can see in the picture here,
this patient is enjoying gaming while on a ventilator
to increase her activity
while standing with the therapist
to promote sort of movement out of bed.
This algorithm is not intended to really focus
on the domains of injury,
however to increase activity levels
for patients with certain deficits.
In future modules,
we will discuss our highly immersive gaming experience
for patients with stroke
that incorporates high intensity, high quality movements
for recovery of multiple domains of post-stroke deficit.
This is essentially changing our paradigm
of post-stroke care and will be discussed at length
in a future discussion.
Taken together, a system of care
that encourages activity after stroke must rely
on a cohesive plan, protocolized activity,
highly specialized individuals working together
to accomplish those goals
and a monitoring system
that identifies any contra-indications
or adverse events secondary to those interventions.
The system of care in the early recovery period relies
on an interdisciplinary team,
each bringing their unique expertise, observational skills,
and innovative planning for each individual patient
to achieve the highest level of function after their stroke.
I hope you have found those extraordinary people
at your facility,
as you can see it requires an army
of specialists, all vigilantly focused on one goal
to improve the life of every stroke patient.
Together we can really make a difference
for each patient to deliver the right therapies
at the right time to each individual.
So to summarize time is critical in the early management
of stroke patients.
What happens in the first few days and weeks are important
to the patients longterm recovery.
Specialized stroke care with attention
to activity is an important part
of the care plan is important in the first few days
after stroke and will reduce complications
if executed properly.
But early activity must be guided by physiologic monitoring
to assure the safety and benefit to each patient.
And finally, teamwork is essential
to bring the right treatment to the right patient
at the right time.
And I wanna thank you for your attention,
I hope this has been a helpful session
for you and I will look forward to conversation
through both email
and in the interactive session coming forward in the future.
Thank you for your attention.