prescribed-video-game-treatment-to-promote-early-recovery-for

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 School of Medicine

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.

Results of a quality-improvement project to enhance safeguards against "wrong-pen-to-patient" insulin pen errors by permitting secure bedside storage of insulin pens are reported.

Randomized controlled evaluation of an insulin pen storage policy.

Evidence suggests that early physical activity can be accomplished safely in the neurocritical care unit (NCCU); however, many NCCU patients are often maintained in a state of inactivity due to impaired consciousness, sensorimotor deficits, and concerns for intracranial pressure elevation or cerebral hypoperfusion in the setting of autoregulatory failure. Structured in-bed mobility interventions have been proposed to prevent sequelae of complete immobility in such patients, yet the feasibility and safety of these interventions is unknown. We studied neurological and hemodynamic changes before and after cycle ergometry (CE) in a subset of NCCU patients with external ventricular drains (EVDs).

Physiological Responses to In-Bed Cycle Ergometry Treatment in Intensive Care Unit Patients with External Ventricular Drainage.

Stroke remains common and is a leading cause of adult disability. While there have been enormous system changes for the diagnosis and delivery of hyperacute stroke treatments at comprehensive stroke centers, few advances have been made in those same centers for treatments focused on behavioral recovery and brain repair. Specifically, during the early hospital period, there is a paucity of approaches available for reduction of impairment beyond what is expected from spontaneous biological recovery. Thus, patients in the early stroke recovery period are not receiving the kind of training needed, at the requisite intensity and dose, to exploit a potential critical period of heightened brain plasticity that could maximize true recovery instead of just compensation. Here, we describe an ongoing pilot program to reconfigure the acute stroke unit experience to allow for a new emphasis on brain repair. More specifically, we have introduced a novel room-based video-gaming intervention; restorative neuroanimation, into the acute stroke hospital setting. This new intervention provides the opportunity for an extra hour(s) of high-intensity neurorestorative behavioral treatment that is complementary to conventional rehabilitation. To accomplish this, system redesign was required to insert this new treatment into the patient day, to properly stratify patients behaviorally and physiologically for the treatment, to optimize the digital therapeutic approach itself, and to maintain the impairment reduction after discharge.

Bringing High-Dose Neurorestorative Behavioral Training Into the Acute Stroke Unit.

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.

Nonpharmacological Treatments for Hospitalized Patients with Stroke: A Nuanced Approach to Prescribing Early Activity.

Maintaining cerebral perfusion in the early stages of recovery after stroke is paramount. Autoregulatory function may be impaired during this period leaving cerebral perfusion directly reliant on intravascular volume and blood pressure (BP) with increased risk for expanding cerebral infarction during periods of low BP and hemorrhagic transformation during BP elevations. We suspected that dysautonomia is common during the acute period related to both pre-existing vascular risk factors and potentially independent of such conditions. Thus, we sought to understand the state of the science specific to dysautonomia and acute stroke. The scoping review search included multiple databases and key terms related to acute stroke and dysautonomia. The team employed a rigorous review process to identify, evaluate, and summarize relevant literature. We additionally summarized common clinical approaches used to detect dysautonomia at the bedside. The purpose of this scoping review is to understand the state of the science for the identification, treatment, and impact of dysautonomia on acute stroke patient outcomes. There is a high prevalence of dysautonomia among persons with stroke, though there is significant variability in the type of measures and definitions used to diagnose dysautonomia. While dysautonomia appears to be associated with poor functional outcome and post-stroke complications, there is a paucity of high-quality evidence, and generalizability is limited by heterogenous approaches to these studies. There is a need to establish common definitions, standard measurement tools, and a roadmap for incorporating these measures into clinical practice so that larger studies can be conducted.

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
Randomized controlled evaluation of an insulin pen storage policy. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists\| PubMed ID: 29222362	2017
Physiological Responses to In-Bed Cycle Ergometry Treatment in Intensive Care Unit Patients with External Ventricular Drainage. Neurocritical care\| PubMed ID: 33751389	2021
Bringing High-Dose Neurorestorative Behavioral Training Into the Acute Stroke Unit. American journal of physical medicine & rehabilitation\| PubMed ID: 36634328	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
Dysautonomia and activity in the early stroke recovery period. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology\| PubMed ID: 38246939	2024

Elizabeth Zink

Biography

JoVE Journal Publications

Other Publications