Transcript Clinical problem solving

“TIME IS BRAIN” AND ITS
INFLUENCE ON STROKE REHAB
REBEKAH RUBIN, SPT
PATIENT CASE
• 64 year old
• White Female
• Admitted to ER
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+ 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
MEDICAL DIAGNOSIS
• Right MCA infarct
•  Ischemic Stroke
• Immediate Treatment IV tPA
• Confirmed by MRI
PATIENT HISTORY
• Medical History: Hypertension, TIA 3 years ago
• Past Surgical History: Right Total Knee(2012), Hysterectomy(1991)
• Medications: Hydrochlorothiazide, Quinapril, Ergocal, Ibuprofen(PRN)
• Family History: Father died from CVA at 68.
PATIENT HISTORY
• Social History:
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Lives 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
INITIAL EVALUATION CONSIDERATIONS
• Evaluation Plan: Out of bed and complete Berg Balance
• Mobility Criteria:
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Secured aneurysm/none identified
MAP 80-110mmHg
HR 40-130 bpm
ICP </= 15 mmHg
Stable neurologic exam
Able to open eyes and move extremities on command
BLOOD PRESSURE PARAMETERS S/P CVA
• Ischemic
• Expect/want SBP High(>160)
• If s/p TPA
• SBP low( <160)
• Tight parameters between (140-160)
• Hemorrhagic
• Want SBP LOW
Ask RN about parameters or look in chart!
PHYSICAL THERAPY ASSESSMENT
Initial Evaluation
Treatment Session #1
Treatment #2
Pain
2/10
Strength L UE
1/5
2/5
2/5
Strength R UE
4+/5
4+/5
functional
Strength L LE
2/5
3/5
3+/5
Strength R LE
4+/5
4+/5
functional
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
Min A x 1
Berg Balance
7/56
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.
PROGNOSIS AND GOALS
• Prognosis: Good
• Patient Goal: Return to function as soon as possible, triathlon?
• PT Goals:
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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.
PLAN OF CARE
• Functional Training with muscle facilitation
• Transfers
• 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
INTERVENTION QUESTION
• 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?
ADVERSE RESPONSE TO TPA
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Active 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
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).
PURPOSE
• Prospective observational safety and feasibility study
• Limited 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
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
METHODS
• Detailed safety checklist and mobilization protocol completed
• Mobilization procedure completed within 24 hours
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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
RESULTS
• 89% of activities did not elicit adverse response
• Average PT onset 19 hours (13-23hrs)
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18/18 were mobilized to EOB or dangled
13 moved to standing
8 transferred to chair
8 ambulated
PATIENT RESPONSE WITH EARLY MOBILIZATION
27% experienced adverse responses:
• Orthostatic
• DBP>105mmHG
• Dizziness
• Neuro changes(transient)
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
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)
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
PARTICIPANTS
Patients randomly assigned from 2004 to 2006
N=71
Inclusion Criteria:
Exclusion Criteria:
• >18 years of age
• Ischemic or hemorrhagic stroke
• Met physiological criteria
• Treatment with TPA allowed
• Admitted within 24 hours
• Significant pre-morbid disability
• Early deterioration
• Direct admission to ICU
• Severe heart failure
• Subarachnoid hemorrhage
• Did not met physiological criteria
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
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
GROUP COMPARISONS
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
RESULTS
Median Number of Days Taken to
Return to Walking 50 m
VEM: 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
Number of Days to walking 50m unassisted
RESULTS
Percent achieving favorable outcome
70%
60%
• SIGNIFICANT
50%
DIFFERENCE only
seen in the 3
month
comparison with
Barthel Index
40%
30%
20%
10%
0%
Barthel 3 Months
Barthel 12 Months
Very Early Mobility
Rivermead 3 Months
Standard Care
Rivermead 12 months
APPLICATION
Earlier and more intensive mobilization in the acute phase of stroke can accelerate
the recovery of walking and functional independence.
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Increased likelihood of being discharged home rather than to rehab
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At 12 months there was no significant group difference for independence in ADLs.
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Limitations
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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
BRINGING IT BACK
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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.
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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.
FUTURE RESEARCH QUESTIONS
• When 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
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), 1168-1173.
doi:10.1016/j.jstrokecerebrovasdis.2015.01.007
• 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), 153-158. doi:10.1161/strokeaha.110.594598
• 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. 2011. 26 (5). Pp 451-459
• Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): A randomised controlled
trial. (2015). The Lancet, 386(9988), 46-55. doi:10.1016/s0140-6736(15)60690-0
• “Neurological Exam & Evaluation.” VCU School of Physical Therapy, 2015
QUESTIONS?