Abstract
Background
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.
Methods
A 55-year-old man was admitted to the Neuroscience Critical Care Unit with an acute thalamic ICH and complex intraventricular hemorrhage requiring placement of two EVDs. Progressive mobilization was achieved using mobility technology devices. Range of motion exercises were performed initially, progressing to supine cycle ergometry followed by incremental verticalization using a tilt table. Physiological parameters were recorded before and after the interventions.
Results
All mobility interventions were completed without any adverse event or clinically detectable change in the patient’s neurological state. Physiological parameters including hemodynamic variables and ICP remained within prescribed goals throughout.
Conclusion
Progressive, device-assisted early mobilization was feasible and safe in this critically ill patient with hemorrhagic stroke when titrated by an interdisciplinary team of skilled healthcare professionals. Studies are needed to gain insight into the hemodynamic and neurophysiological responses associated with early mobility in acute stroke to identify subsets of patients who are most likely to benefit from this intervention.
Similar content being viewed by others
References
Diserens K, Michel P, Bogousslavsky J. Early mobilisation after stroke: review of the literature. Cerebrovasc Dis. 2006;22:183–90.
Markus HS. Cerebral perfusion and stroke. J Neurol Neurosurg Psychiatry. 2004;75:353–61.
Dawson SL, Panerai RB, Potter JF. Serial changes in static and dynamic cerebral autoregulation after acute ischaemic stroke. Cerebrovasc Dis. 2003;16(1):69–75.
Bernhardt J, Churilov L, Ellery F, et al. Prespecified dose–response analysis for a very early rehabilitation trial (AVERT). Neurology. 2016;86:1–8.
AVERT Trial Collaboration Group, Bernhardt J, Langhorne P, et al. Efficacy and safety of very early mobilization within 24 hours of stroke onset (AVERT): a randomized controlled trial. Lancet. 2015;386:46–55.
Hemphill JC, Bonovich DC, Besmertis L, Manley GT, Johnston C. The ICH Score: a simple, reliable grading score for intracerebral hemorrhage. Stroke. 2001;32:891–7.
Morandi A, Brummel NE, Ely EW. Sedation, delirium and mechanical ventilation: the ‘ABCDE’ approach. Curr Opin Crit Care. 2011;17:43–9.
Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA. 2008;300:1685–90.
Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference. Crit Care Med. 2012;40:502–9.
Klein K, Mulkey M, Bena JF, Albert NM. Clinical and psychological effects of early mobilization in patients treated in neurologic ICU: a comparative study. Crit Care Med. 2015;43:865–73.
Cumming TB, Thrift AG, Collier JM, et al. Very early mobilization after stroke fast-tracks return to walking: further results from the phase II AVERT randomized controlled trial. Stroke. 2011;42(1):153–8.
Barer D, Watkins C. Could upright posture be harmful in the early stages of stroke? Lancet. 2015;386(10005):1734–6.
Olavarría VV, Arima H, Anderson CS, et al. Head position and cerebral blood flow velocity in acute ischemic stroke: a systematic review and meta-analysis. Cerebrovasc Dis. 2014;37:401–8.
Aries MJ, Elting JW, Stewart R, De Keyser J, Kremer B, Vroomen P. Cerebral blood flow velocity changes during upright positioning in bed after acute stroke: an observational study. BMJ Open. 2013;3:e002960.
Thelandersson A, Nellgård B, Ricksten SE, Cider Å. Effects of early bedside cycle exercise on intracranial pressure and systemic hemodynamics in critically Ill patients in a neurointensive care unit. Neurocrit Care. 2016;25(3):434–9.
Baltz MJ, Lietz HL, Sausser IT, Kalpakjian C, Brown D. Tolerance of a tilt table protocol in an inpatient stroke unit setting: a pilot study. J Neurol Phys Ther. 2013;37(1):9–13.
Frazzitta G, Valsecchi R, Zivi I, et al. Safety and feasibility of a very early verticalization in patients with severe traumatic brain injury. J Head Trauma Rehabil. 2015;30(4):290–2.
Acknowledgements
The authors would like to acknowledge the enthusiastic work of the Johns Hopkins Hospital NCCU staff and the rehabilitation therapists for their participation in the early mobility project. We also acknowledge Sara Combilizer®Arjo Huntleigh Group for providing the Sara Combilizer tilt table for trial for few months.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
None.
Rights and permissions
About this article
Cite this article
Kumble, S., Zink, E.K., Burch, M. et al. Physiological Effects of Early Incremental Mobilization of a Patient with Acute Intracerebral and Intraventricular Hemorrhage Requiring Dual External Ventricular Drainage. Neurocrit Care 27, 115–119 (2017). https://doi.org/10.1007/s12028-017-0376-9
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12028-017-0376-9