1 “Time is Brain” and Its Influence on stroke rehabRebekah Rubin, SPT Hi guys today I’m going to be presenting my case on stroke and the early start of rehab. The hospital I was at this summer was transitioning it’s stroke rehab treatment to include evaluations w/n the first hours of admission.

2 Patient Case 64 year old White Female Admitted to ER+ L facial droop + L sided paralysis(UE>LE) + L sensation decreased + visual disturbances NIHSS on admission 14 CT completed within 2 hours of symptom onset Eye deviation toward the right NIHSS ntional institutes of health stroke scale-most commonly used for evaluating and quanitifying stroke severity with thte highest score of a 42 coinciding with a severe stroke. We learned in class that a Score of >/= 16 idicates high probability of death or severe disability so this pateint was just below that and was categorised as having a moderate stroke CT scan ruled out hemmorage so they were able to proceed with treatment

3 Medical Diagnosis Right MCA infarct Confirmed by MRI  Ischemic StrokeImmediate Treatment IV tPA Confirmed by MRI That treatment consistened of immediate TPA administration for a Right Middle Cerebral Artery infarct most likely due to a thrombus. The MRI was used to confirm the diagnosis hours later.

4 Patient History Medical History: Hypertension, TIA 3 years agoPast Surgical History: Right Total Knee(2012), Hysterectomy(1991) Medications: Hydrochlorothiazide, Quinapril, Ergocal, Ibuprofen(PRN) Family History: Father died from CVA at 68. To back track for a second I’m going to go over a bit of the patient’s history. Overall she lived a very healthy lifestyle but she did have hypertension and did present with a transient ischemic attack three years ago. The medications she is currently on are to manage her blood pressure and a vitamin D supplement. She is very active and takes IB seldomly She does has a positive family history as her father died at 68 from a stroke Hypertension medications/ Quinapril-ACE inhibitor-relaxes blood vessels Hyro-diuretic Ergocal-Vitamin D supplement

5 Patient History Social History: Prior Level of Function: IndependentLives with husband in a two story house 3 children live nearby Volunteers at church and cares for grandchildren Denies smoking and only drinks occasionally (3-4 drinks/week) Prior Level of Function: Independent Active-works out 4x/week A bit on her social history: she lives with her husband ans they have three children that live nearby. She is recently retired and very active in the community and watches over her grandkids often. Denies smoking but admits to having a drink everyone in a while. Prior to coming into the hospital she was very independent with all activities and has only used an assistive device for her knee replacement. She works out 4 times a week and is training for triatholon

6 Initial Evaluation ConsiderationsEvaluation Plan: Out of bed and complete Berg Balance Mobility Criteria: Secured aneurysm/none identified MAP mmHg HR bpm ICP Stable neurologic exam Able to open eyes and move extremities on command Going into an initial eval for a neuro patient who just recently had a stroke there are a few things to take into consideration before beginning care. At the hospital this summer the goal for every initial eval is to have the patient complete the Berg Blanace test which involves having the patient try to get out of bed. Before beginning and during the treatment it’s important to monitor the patients vitals and they must be able to follow commands before getting them out of bed.

7 Blood Pressure Parameters s/p CVAIschemic Expect/want SBP High(>160) If s/p TPA SBP low( <160) Tight parameters between ( ) Hemorrhagic Want SBP LOW In the case of this patient she was treated with TPA so the blood pressure parameters are tighter to decrease adverse reactions when typically we would be ok with having a higher systolic BP for increased perfusion this was not the case. Ask RN about parameters or look in chart!

8 Physical Therapy AssessmentInitial Evaluation Treatment Session #1 Treatment #2 Pain 2/10 Strength L UE 1/5 2/5 Strength R UE 4+/5 functional Strength L LE 3/5 3+/5 Strength R LE Bed Mobility Mod A x1 Min A x 1 Mod I Sit to Stand Max A x 1 Min Ax1 CGA Ambulation Max A x 1 + HHA Mod Ax1 Berg Balance 7/56 I have made a chart of the objective measures between initial eval through the 2nd follow up treatment. We were then moved to a different hospital and was unable to follow up for the remainder of her time there. The patient was making good progress with therapy in just the first three days and was showing imporvement in strength especially of the L LE

9 PT Diagnosis Patient diagnosed with R MCA ischemic stroke, onset 15 hours prior, presents with left sided weakness, static and dynamic balance deficits and decreased coordination, which puts patient at a high fall risk, limiting safe ambulation and ability to transfer independently. Patient is below her baseline level of function.

10 Prognosis and Goals Prognosis: GoodPatient Goal: Return to function as soon as possible, triathlon? PT Goals: In 1 week patient will increase Berg Balance Score by 6 points to show decreased fall and safety risk. In 1 week patient will be SBA for all transfers and ambulation to return home with husband and family. In 1 week patient will verbally communicate understanding of exercise program, safety precautions and signs and symptoms of stroke. I gave the patient a Good prognosis based on her age, desire to get better, improvements already already being seen in strength and function, she was also treated quickly, has the family support, and led an active lifestyle. The goals we set for the patient revolved around safety and reaching SBA for ambulation and transfers so she could return home and regain independence

11 Plan of Care Functional Training with muscle facilitationTransfers Bed Mobility Balance Activities Sitting EOB/Standing EOB Reaching out of BOS Gait Training Education Plan: Pt will be been 5x/week anticipated D/C home or inpatient rehab Our plan of care spent the majority of the time out of bed and working on functional balance activites such as reaching out of the base of support and remaining balanced with head turns and perturbations. Our plan was to see the pt daily while she was in acute care before returning home with OP rehab or to inpatient rehab depending on her progress.

12 Intervention QuestionFor a 64 year old female given TPA for ischemic stroke, is mobility in the first 24 hours a safe and effective means to decrease hospital stay and reduce time of recovery to a favorable outcome?

13 Adverse Response to TPAActive bleeding Diaphoresis HR <40 or >130 bpm Orthostatic hypotension Increased DBP >105mmHG Significant increase or decrease in SBP and RR Shortness of breath Anxiety, pain, syncope Neurological changes A quick review on some of the adverse responses to TPA are listed here. A large reason mobility is withheld for patient who receives TPA is because of the thought that mobilizing earlier will increase the chance of bleeding and have neurologic worsening so its important to keep an eye out for any changes in HR, BP, or if you notice bleeding in any patient lines.

14 Research “Very Early Mobilization in Stroke Patients Treated with Intravenous Recombinant Tissue Plasminogen Activator” Arnold, S. M., Dinkins, M., Mooney, L. H., Freeman, W. D., Rawal, B., Heckman, M. G., & Davis, O. A. (2015). The first article wea re going to look at access mobility in patient treated with IV TPA and its from 2015

15 Purpose Prospective observational safety and feasibility studyLimited data regarding the safety of early mobilization status post acute ischemic stroke (AIS) patients who receive tPA Currently there is considerable variety regarding the timing of rehab after tPA Hypothesis: PT and OT would be safe when initiated within 24 hours after IV TPA in patients with a stroke It is a prospective observational study on safety and feasibility There is considerable variety amoung US hospitals regarding the timing of rehabilitation efforts for patients who have been treated with IV tPA after stroke. Some hospitals routinely recommend bedrest for the first 24 hours after administration, and others recommend bedrest for up to 48 hours. There are others with no guidelines. The hypothesis was that PT and OT would be safe in terms of major bleeding and other neurological events when initiated within 24 hours after IV TPA in patients with a stroke

16 Participants June 2011-July 2012 N=18 Inclusion Criteria:18 years or older Issued TPA Able to engage in out of bed mobilization within 24 hours of TPA Hemodynamically stable Exclusion Criteria: No consent given Hemodynamic instability HR >100bpm Hypotensive Hypertensive Collected data for about a year. Started with 41 patients who were administered Iv rtPA---30 patients formally consented and underwent early mobilization----MRI at 24 hours given to confirm ischemic stroke. Acute ischemic stroke was ruled out in 12…leaving the final number at 18 Inclusion criteria included receiving TPA, being hemodynamically stable and able to mobilize out of bed within 24 hours 7 minor stroke NIHSS <7 6 moderate stroke 5 severe >15

17 Methods Detailed safety checklist and mobilization protocol completedMobilization procedure completed within 24 hours 1) Rise from supine to sitting EOB 2) Stand at the side of the bed 3) Transfer from bed to chair 4) Ambulate Data was collected on all adverse outcomes Protocol included monitoring heart rate and BP before, during and after mobilization and inspection of IV sites and wounds to verify the absence of activ ebleeding before and after mobilization. Mobilization had to occur within 24 hours and the session progressed from sitting on the EOB to ambulating. If an adverse event occurred treatment was immediately terminated regardless of the severity.

18 Results 89% of activities did not elicit adverse responseAverage PT onset 19 hours (13-23hrs) 18/18 were mobilized to EOB or dangled 13 moved to standing 8 transferred to chair 8 ambulated 42 of 47 mobilization activities elicited no adverse response The avergae time to start treatment was 19 hours and all 18 patients made it to the EOB(seeing as though that was part of the inclusion criteria it was expected). 13 moved to standing and 8 each transferred to the chair and walked anywhere from feet

19 Patient Response with Early Mobilization27% experienced adverse responses: Orthostatic DBP>105mmHG Dizziness Neuro changes(transient) Here is a chart of the adverse responses they were looking for. 5 patients did experience some kind of adverse response. With the most common being orthostatic hypotension. One patient experienced both ortostasis and neurologic signs Dizziness was reported after one patient walked 20 feet

20 Application Over 72% of patients tolerated mobilization within 24 hours after receiving TPA without any adverse responses Those reported were mild, transient and non-life threatening With consistent monitoring early mobilization in AIS patients after IV rtPA has the potential to reduce hospital and ICU length of stay and start an earlier, more aggressive rehab process without increased safety concerns. Limitations of the study: Small sample size No control group No attempt taken to control for comorbidities The majoirty of patients mobilized w/o any adverse effects ad those that were reported were mild and non-life threating So From this study researches concluded that with consistent monitoring early mobilization after TPA does have the potential to decrease length of stay and open a window to start an earlier rehab process w/o increased safety concerns. A few limitations were the small sample size and lack of contorl group, plus they did not take into acount any of the patients comorbidities

21 Research “Very Early Mobilization After Stroke Fast-Tracks Return to Walking. Further results from the Phase II AVERT Randomized Controlled Trial” Toby B. Cumming, PhD; Amanda G. Thrift, PhD; Janice M. Collier, PhD; Leonid Churilov, PhD; Helen M. Dewey, PhD; Geoffrey A. Donnan, MD; Julie Bernhardt, PhD (2010) The second artcile we are going to look at it part of the phase 2 trial of a three phase international, multi-center trial on early mobility after a stroke. This article is from 2010.

22 AVERT(A Very Early Rehabilitation Trial)Design: Prospective Randomized Control Trial, intention-to-treat analysis, blinded assessment of outcomes Location: 2 large hospitals, Australia Purpose: Aimed to compare the effectiveness of frequent, higher dose, very early mobilization with standard care after stroke. Primary Outcome Measure: Time to walk 50m It is a prospective Randomized contorl trial that was conducted in to hospital in Melborne. Its goal was to compare the effectiveness of frequent, higher dose early mobility versus standard care and the researches hypothesized that introduing earlier and more intensive out-of bed activty after a stroke would reduce time to unassisted walking and improve independence in ADLs

23 Participants Patients randomly assigned from 2004 to 2006 N=71Inclusion Criteria: >18 years of age Ischemic or hemorrhagic stroke Met physiological criteria Treatment with TPA allowed Admitted within 24 hours Exclusion Criteria: Significant pre-morbid disability Early deterioration Direct admission to ICU Severe heart failure Subarachnoid hemorrhage Did not met physiological criteria Inclusion criteria was similar to the first article that being they had to meet certain physiological criteria of SBP between 120 and 220 mmHG, HR between 40 and 100 bpm, O2 saturation above 92% Patients with More severe comorbidities were excluded from this trial

24 Methods Patients randomly assigned to Very Early Mobilization(VEM group) or Standard Care(SC) group VEM group criteria: 1) begin mobilization as soon as practical 2) focus on upright and out of bed interventions 3) sessions at least twice a day Intervention lasted 14 days or until D/C from stroke unit Randomization was stratified by study location and stroke severity according to the NIHSS(Health stroke scale) Components of usual care were at the discretion of individual sites Strict guidelines for the first session with mobilization out of bed only if the patients blood pressure did not drop by more than 30 mm HG upon upright positioning The very early mobility group was to get out of bed as soon as practical and received treatment twice a day with either nursing or PT

25 Outcomes Assessments took place at 7 and 14 days and 3, 6 and 12 months after stroke Primary: Time to walk 50m unassisted Secondary: Barthel Index Rivermead Motor Assessment Safety Outcome: Death at 3 months A blinded outcome assessor took measurements a 7 and 14 days and then 3, 6 and 12 months later. Primary outcome was the Time to walk 50 m which is a distance used in the functional independence measure and is routinely marked out in hospitals. Pts able to use walking aid but not allowed “human help” Barthel Index: is a valid and reliable measure to assess independence in 10 everyday tasks. Max score of 20 with the higher scores reflecting higher performance. Rivermead Motor Assessment is a gross function scale of 13 items to examine motor activity. It uses (easy to difficult items) from sitting to walking and running outdoors. Scores 9 and below are perceived as impaired. Patient who died during data collection were assigned a score of 0 on the two secondary outcome measures to reduce biased results.

26 Group Comparisons Death at 3 months and 12 months:VEM(N=38) Standard Care(N=33) Time to evaluation 18 hours 31 hours Total amount per person 167 min 69 min Length of Stay in Acute Care 6 days 7 days Discharged Directly Home 32% 24% Death at 3 months and 12 months: *NO Significant difference between groups when adjusted The chart at the top shows the difference in treamtent dose between the two groups where the standard care group received the initial treatment on average 10 hours later and received only 40% of what the early mobility group received. Those in the very early mobility group did tend to have a shorter acute stay and a larger percent D/Cd home The flow chart below includes the unnmbers per group and adjusts out for deaths. There was no significant difference for death rate at either 3 or 12 months When adjusted for severity and premorbid condition. the VEM group had higher percentages of patients with moderate and severe strokes as well as higher level of disability before stroke so there was a higher likelihood that they would pass away byt the 12 month mark

27 Results Median Number of Days Taken to Return to Walking 50 mVEM: 3.5 Days SC: 7 Days 2 weeks post-stroke VEM: 67% completed 50m walk SC: 50% completed 50m walk *SIGNIFICANT difference p=0.032 This chart displays the 50 m unassisted walking task and you can see there is a significant difference between the two groups with the higher line represneting the early mobility group. Meidan time to return to walking 50m was 3.5 days vs. 7 It is Adjusted for age, sex, stroke severity Of the patients who achieved goal142 days was the longest it took for a patient to return to walking Earlier return to walking after stroke was also independently associate with less severe stroke, younger age and absense of diabetes Number of Days to walking 50m unassisted

28 Results Percent achieving favorable outcome SIGNIFICANT DIFFERENCE only seen in the 3 month comparison with Barthel Index I created a bar graph displaying the differences between the functional outcome measures at 3 and 12 months with the Barthel and Rivermead Index Barthel score of 20 or rivermead score od 10-13 Having a good outcome on the Barthel index at three months was independently associated with exposeure to the very early mobilitlity treatment and was the only measure that showed a significant difference between groups. Age and stroke severity strongly influenced recovery at 3 and 12 months after stroke with those achieving greater independence. The negative influence of diabetes on functional independence was found in walking recovery and the Barthel index at 12 months

29 Application Earlier and more intensive mobilization in the acute phase of stroke can accelerate the recovery of walking and functional independence. Increased likelihood of being discharged home rather than to rehab At 12 months there was no significant group difference for independence in ADLs. Limitations Varied PT interventions Dose Response? Wide confidence intervals around effect of intervention Ceiling effect in Barthel Index Barthel nor Rivermead incorporate death into their outcomes Witht hese results it showed that earlier and more intense mobilization in the acute phase of stroke can accelerate the recovery of walking and functional independence. But that being said there was little difference at 12 months in terms of independence in ADLs. Some limitiations that came into play were the lack of standarization of intervention, the increased dose that the early mobility group received could have very easily affected the results and the ceiling effect of the Barthel index was achieveed by many as they reached the max of 20 points early

30 Bringing it back For a 64 year old female given TPA for ischemic stroke, is mobility in the first 24 hours a safe and effective means to decrease hospital stay and reduce time of recovery to a favorable outcome? Safety? Yes-Probably Safe Effective? Yes-Not ineffective Overall Impression: It depends. All patients: Complete a through neuro assessment and unless there is a valid concern or contraindication mobilizing out of bed and promoting functional recovery doesn’t need to wait. To reiterate the question and bring it back to my patient do I think mobility in the first 24 hours is a safe and effective measure to reduce the time to a favorable outcome? I’d say yes. But the overall impression is that it really depends on the individual patient but as long as the patient is hemodynamically stable and side effects are monitored the adverse side effects are not harmful enough to warrant the patient remaining in bed.

31 Future Research QuestionsWhen is the best time to start rehabilitation after a stroke? What should intervention consist of? Who should be targeted early? Evidence-Based Practice: AVERT Phase II showed significantly faster return to function in early mobility group AVERT Phase 3 just wrapped up and was expecting to enroll ~380 pts treated with TPA A more concrete understanding of who responds to threatment, who does not and why is still missing.

32 References Arnold, S. M., et al. (2015). Very Early Mobilization in Stroke Patients Treated with Intravenous Recombinant Tissue Plasminogen Activator. Journal of Stroke and Cerebrovascular Diseases, 24(6), doi: /j.jstrokecerebrovasdis Cumming, T. B., Thrift, A. G., Collier, J. M., Churilov, L., Dewey, H. M., Donnan, G. A., & Bernhardt, J. (2010). Very Early Mobilization After Stroke Fast-Tracks Return to Walking: Further Results From the Phase II AVERT Randomized Controlled Trial. Stroke, 42(1), doi: /strokeaha Discerens, K, et al. Early Moblilization out of bed after ischemic stroke reduces severe complications but not cerebral bllod flow: a randomized colntrolled pilot study. Clinical Rehabilitation (5). Pp Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): A randomised controlled trial. (2015). The Lancet, 386(9988), doi: /s (15) “Neurological Exam & Evaluation.” VCU School of Physical Therapy, 2015

33 Questions?