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Prescribed Video Game Treatment to Promote Early Recovery for Hospitalized Stroke Patients: Concepts in Standardized Implementation

Patients with stroke often have upper limb impairment that impacts function and quality of life. Increased amounts of arm training in the early phase post ...

Johns Hopkins Hospital

Recent trials have challenged the notion that very early mobility benefits patients with acute stroke. It is unclear how cerebral autoregulatory impairments, prevalent in this population, could be affected by mobilization. The safety of mobilizing patients who have external ventricular drainage (EVD) devices for cerebrospinal fluid diversion and intracranial pressure (ICP) monitoring is another concern due to risk of device dislodgment and potential elevation in ICP. We report hemodynamic and ICP responses during progressive, device-assisted mobility interventions performed in a critically ill patient with intracerebral hemorrhage (ICH) requiring two EVDs.

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

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

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

To measure the impact of a progressive mobility program on patients admitted to a neurocritical critical care unit (NCCU) with intracerebral hemorrhage (ICH). The early mobilization of critically ill patients with spontaneous ICH is a challenge owing to the potential for neurologic deterioration and hemodynamic lability in the acute phase of injury. Patients admitted to the intensive care unit have been excluded from randomized trials of early mobilization after stroke.

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

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

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

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

Article	Year
Physiological Effects of Early Incremental Mobilization of a Patient with Acute Intracerebral and Intraventricular Hemorrhage Requiring Dual External Ventricular Drainage. Neurocritical care\| PubMed ID: 28243999	2017
Feasibility of Early, Motor-Assisted Cycle Ergometry in Critically Ill Neurological Patients With Upper Limb Weakness and Variable Cognitive Status: A Case Series. American journal of physical medicine & rehabilitation\| PubMed ID: 29095167	2018
Safety and Feasibility of a Neuroscience Critical Care Program to Mobilize Patients With Primary Intracerebral Hemorrhage. Archives of physical medicine and rehabilitation\| PubMed ID: 29580936	2018
Development and Implementation of a Standard Assessment Battery Across the Continuum of Care for Patients After Stroke. American journal of physical medicine & rehabilitation\| PubMed ID: 36634331	2023
Nonpharmacological Treatments for Hospitalized Patients with Stroke: A Nuanced Approach to Prescribing Early Activity. Neurotherapeutics : the journal of the American Society for Experimental NeuroTherapeutics\| PubMed ID: 37289401	2023

Sandra Deluzio

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