Special Considerations for Mobilizing Patients in the Neuro ICU Mary Jo Kocan, MSN, RN, CNRN Clincal Nurse Specialist, Hendrika Lietz, PT, DPT, NCS Clinical Specialist

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Special Considerations for Mobilizing Patients in
the Neuro ICUMary Jo Kocan, MSN, RN, CNRN
Clincal Nurse Specialist,Hendrika Lietz, PT,
DPT, NCS Clinical Specialist Physical Therapist

• University of Michigan Health System

2
The Why

• The benefits of early mobility in critical care
  patients have been well described through out
  this course and in the literature
• shorter ICU and hospital LOS, improved quality of
  life and earlier return to independent
  functioning 1, 2, 3
• weakness occurs due to the interplay of bedrest,
  critical illness, neuromuscular blockade and
  prolonged sedation 4, 5, 6

3

• In the neurologically impaired patient
  population, weaning sedation and analgesics
  doesnt necessarily result in a responsive,
  cooperative patient.
• Due to the underlying brain injury, there is no
  potential for a holiday

4
Early Intervention for the Neurologically Impaired

• Patients with neurologic illness or injury also
  benefit from early interventions to increase
  physical activity and mobility with
• improved functional outcomes
• earlier return to independent ambulation10
• report lower depression scores in the early
  stages following stroke 11
• higher quality of life related to independent
  living at one year. 12,

5
Neurointensive Care unit

• neurointensive care unit patients also have
  special needs related to
• hemodynamic stability
• intracranial pressure (ICP) dynamics
• neurologic deficits

6
Increased Intracranial pressure(ICP) and Cerebral
Perfusion

• Increased ICP and altered cerebral perfusion
  accompany many neurologic illnesses.
• Cerebral autoregulation is the ability of the
  cerebral blood vessels to dilate and constrict to
  maintain a constant cerebral blood flow

7
ICP continued

• Postural decreases in BP can contribute to
  cerebral ischemia
• Increases in BP due to agitation or strenuous
  activity can increase cerebral blood volume and
  increase ICP.

8
Ventriculostomy

• The Ventriculostomy is a catheter placed in the
  ventricles of the brain to drain excess Cerebral
  Spinal fluid and/ or excess blood which is not
  being reabsorbed through the arachnoid villi ,
  causing increasing Intracranial Pressure (ICP)
  and potential secondary injury to the CNS.
• Is postioned in alingement with the tragus and
  functions by pressure gradient.

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Ventriculostomy and Mobility

• A patient can still be mobilized with a
  ventriculostomy in place as long as
• It is approved by Medical Team
• It is clamped by NURSING STAFF
• ICP is stable and maintains between 3 and 18
  mmHg ( can go slightly out of range if nursing
  approves)

10
BP and Spinal Cord Injury

• After acute spinal cord injury, disruption of the
  sympathetic nervous system can cause
• peripheral vasodilatation and bradycardia.
• This effect is exaggerated with changes in body
  position like head elevation or having the legs
  in a dependent position, and can result in
  decreased perfusion to all major organ systems as
  well as to the spinal cord.

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Motor Deficit and Mobility

• Neurologic deficits may impede a patients
  functional ability, making them less able to
  participate in self-care activities and mobility
  within the ICU
• Mobilizing a patient with focal motor deficits
  may require
• specialized adaptive equipment
• various assistive devices
• additional personnel.

12
Language Deficit and Mobility

• Language deficits may impair the patients
  ability to
• understand directions
• communicate tolerance of physical activity
• May require cognitive strategies such as the use
  of gestures, facial expression and tone of voice
  to facilitate participation. 14

13
Neuroplasticity

• Plasticity, the ability of neurons to alter their
  structure and function, enables the damaged brain
  to relearn lost behaviors in response to
  rehabilitation. 15
• Among other processes, plasticity involves
  recruitment of previously silent redundant
  pathways, dendritic sprouting, formation of new
  synapses and recruitment of perilesional
  neurons.16

14
The Critical Window and Neuroplasticity

• Studies indicate there is a critical time window
  after brain injury when neuroplasticity is
  heightened to optimize motor recovery.
• In an animal study, providing an enriched
  environment at 5, 14 and 30 days after injury,
  only the animals who received enrichment at day 5
  displayed dendritic and synaptic growth. 7 .

15
What if they cant move themselves?

• A systematic review of post stroke brain
  reorganization indicated that after brain injury,
  moving paralyzed limbs even passively helps
  promote neural plasticity, re-routing signals
  around the injured area and forming new
  connections, resulting in improved functional
  recovery. 16

16
Initiating mobility for the neurologic patient

• In deciding when and how to initiate mobility for
  the neurologic patient, the clinical team must
  Consider the full spectrum of mobility
• Passive range of motion,
• Bed chair positon -gtOEB supported or unsupported
• Standing and ambulation

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Special Considerations Based on
Diagnosis/Clinical Condition Ischemic Stroke

• Critical Indicator Hemodynamic Stability
• Cerebral perfusion may be dependent on elevated
  systemic blood pressure.
• Monitor the patient for signs of ischemia
  related to BP changes such as
• increased lethargy,
• increased weakness
• increase in language dysfunction.

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Special Considerations Based on
Diagnosis/Clinical Condition Subarachnoid
Hemorrhage

• Critical Indicator BP, Volume Status, presence
  of Vasospasm
• Prior to the aneurysm being secured, patient
  activity is usually limited in order to prevent
  rebleeding.
• Restrictions include
• bedrest and limitations on environmental stimuli
  close monitoring of blood pressure and
  intracranial pressure. 20
• Once the aneurysm is secured, stability for
  mobilization is dependent upon blood pressure
  (BP), volume status and the risk or presence of
  vasospasm.

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Special Considerations Based on
Diagnosis/Clinical Condition Subarachnoid
Hemorrhage

• Critical Indicator BP, Volume Status, presence
  of Vasospasm
• Prior to the aneurysm being secured, patient
  activity is usually limited in order to prevent
  rebleeding.
• Restrictions include
• bedrest and limitations on environmental stimuli
  close monitoring of blood pressure and
  intracranial pressure. 20
• Once the aneurysm is secured, stability for
  mobilization is dependent upon blood pressure
  (BP), volume status and the risk or presence of
  vasospasm.

20
Special Considerations Based on
Diagnosis/Clinical Condition Subarachnoid
Hemorrhage

• Know BP goals -monitor blood pressure in response
  to activity to avoid relative hypotension.
• Depending on the location of the aneurysm,
  -behavioral considerations
• agitation,
• impulsivity
• poor short-term memory
• seen in many patients with anterior communicating
  artery aneurysms.

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Special Considerations Based on
Diagnosis/Clinical Condition TBI/Hemicraniectomy

• Critical Indicator Stability of ICP
• The upper limit of normal ICP is 15mmHg
  treatment is usually initiated if ICP is
  sustained above 20mmHg.
• , monitor ICP closely and stop the intervention
  if ICP exceeds this limit and does not return to
  normal levels within minutes.
• hemicraniectomy for intractable brain swelling or
  increased intracranial pressure,
• the patient will need to wear a helmet for
  protection,
• cannot be fitted until after the ICP monitor is
  removed.
• Depending on the patients level of
  responsiveness, head support may be required when
  in a chair.

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Special Considerations Based on
Diagnosis/Clinical Condition Spinal Cord Injury

• Critical Indicators Spinal Stabilization,
  postural hypotension, pressure relief
• Spine must be cleared by medical team for upright
  activity
• Guard for effects decreased autonomic innervation
  below level of lesion- Juzos and abdominal
  binder needed at bedside for mobilization
• Decreased sensation below level of lesion-needs
  frequent pressure relief (15-20 minutes)- educate
  patient, staff , and family

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How to Mobilize the Neurologically Impaired
Patient

• In Summary the specifics of mobility and its
  progression is functionally based as in previous
  presentations , specifically they are dependent
  on
• Special considerations-diagnosis specific
• Level of cognitive arousal- no sedation holiday
• Motor Impairments
• Executive Function Impairments

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Use of a Tilt Table to provide Early Mobility

• VIDEO

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Tolerance of a Standing Tilt Table Protocol in a
Stroke Unit Setting A Pilot StudyHendrika
Lietz, PT, NCS Ida Sausser, MPT Mathew Baltz,
DPT Claire Kalpakjian, PhD Devin Brown, MD

• Funded with a grant from the Practiced-Oriented
  Research Program (PORT) at the University of
  Michigan

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• STANDING TILT TABLE PROTOCOL
• Elevated participants (head-up tilt) in a
  step-wise manner from 0, 45, 60, 70, 80 and 90
  degrees.
• Tolerance was defined as being able to maintain
  all physiologic and objective measures of
  tolerance at a level 60 degrees for above on the
  tilt table for greater than 5 minutes.
• Tolerance at each angle was defined by the
  following
• Objective indices of tolerance included
  monitoring of systolic blood pressure, diastolic
  blood pressure, heart rate, oxygen and clinical
  observation of dyspnea, pallor, diaphoresis or
  mental status changes.
• Subjective indices of tolerance included rating
  of perceived exertion, pain and no report of
  angina, dizziness, excessive fatigue, nausea,
  anxiety or subjective request to be lowered.

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BACKGROUND

• Patients hospitalized within a stroke unit have
  impairments that prevent them from safely
  transferring out of bed. Moreover, immobility can
  lead to multiple medical complication and
  increases the rate of functional decline
• 
  1,2,3

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• Early and advanced mobility programs for the
  stroke patient,, have been found to improve
• Overall gait and functional outcomes4,5
• Increase the likelihood of discharge directly
  home from a combined acute inpatient
  rehabilitation stroke unit 6
• Bone density, reduced pain, cardiopulmonary
  function, gastrointestinal motility and improved
  functional recovery following stroke 7,8

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• Nevertheless, multiple barriers exist to
  mobilizing patients7 and best practice standards
  have not been established.
• The use of a tilt table to mobilize patients is a
  recognized rehabilitation tool9,10 but studies on
  safety and tolerability in acute stroke patients
  have not been performed.

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PRIMARY OBJECTIVES

• The primary objective of this research was to
  examine the tolerability of a title table
  protocol implemented within 24-72 hours of admit
  to the acute stroke unit. Specifically, we
  assessed
• physiologic and subjective tolerance of a
  standing tilt table protocol (STTP)
• maximum angle of inclination achieved
• maximum duration of standing time
• Association of type of stroke, selected
  co-morbidities and time to tilt with tolerance

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METHODS

• This prospective, observation study was conducted
  within an Acute Stroke Care Unit for adults at a
  major University Medical Center in the Midwestern
  United States.
• One hundred and fifty one patients were screened
  for inclusion 36 met criteria and completed the
  protocol 22 females (61.1), 24 to 87 years (62
  16 years) with ischemic (25, 69.4) and
  hemorrhagic (11, 30.6) strokes

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STANDING TILT TABLE PROTOCOL

• Elevated participants (head-up tilt) in a
  step-wise manner from 0, 45, 60, 70, 80 and 90
  degrees.
• Tolerance was defined as being able to maintain
  all physiologic and objective measures of
  tolerance at a level 60 degrees for above on the
  tilt table for greater than 5 minutes.
• Tolerance at each angle was defined by the
  following
• Objective indices of tolerance included
  monitoring of systolic blood pressure, diastolic
  blood pressure, heart rate, oxygen and clinical
  observation of dyspnea, pallor, diaphoresis or
  mental status changes.
• Subjective indices of tolerance included rating
  of perceived exertion, pain and no report of
  angina, dizziness, excessive fatigue, nausea,
  anxiety or subjective request to be lowered.

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RESULTS

• 53 of subjects attained 60 degrees or higher
  (See Table 1) with a mean total standing time of
  8.9 minutes.
• The most common factor for terminating a trial at
  any angle was exceeding the diastolic blood
  pressure parameters (See Figure 1).
• There was no significant association between
  stroke type and tolerance above 60 degrees (X2
  0.341, p 0.56), the presence of diabetes (X2
  0.341, p 0.56), myocardial infarction (X2
  1.2, p 0.41), or cancer (X2 4.03, p 0.11),
  discharge disposition (X2 2.05, p 0.36) or
  length of stay (t -0.61, p 0.54).
• Tolerance improved following a 24 hour time
  period post hospital admission (See Figure 3).

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Table 1. Maximum Angle Achieved by Participants

• Maximum Angle Achieved
  N ()
• Unable to Achieve Lowest Angle
  10 (27.8)
• 45 Degrees
  7 (19.4)
• 60 Degrees
  4 (11.1)
• 70 Degrees
  8 (22.2)
• 80 Degrees
  1 (2.8)
• 90 Degrees
  6 (16.7)

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CLINICAL IMPLICATIONS/CONCLUSION

• The results of this pilot study suggests that a
  STTP is a viable option to safely assist patients
  into prolonged standing when otherwise
  immobilized
• 24 hours after hospital admission and diagnosis
  of ischemic and hemorrhagic stroke
• For a duration of 10 minutes
• And using a step-wise progression for an angle
  up to 70 degrees (94 of body weight borne).
• The main limiting factor for tolerance to
  standing and discontinuance of progressive angle
  of inclination was diastolic variability.
  Variability in diastolic and systolic blood
  pressures were the two main limiting factors to
  tolerance, respectively.
• Given our results with strict, conservative ,
  operational definitions of blood pressure
  tolerance , and no change in neurological
  deficit when intolerance was present, the use of
  other clinical measures, which attempt to assess
  cerebral perfusion such as the mean arterial
  pressure (MAP), might possibly enhance the
  assessment of tolerance of a STTP.
• The next step is to test this protocol in a
  larger sample of participants with or without
  other diagnosiss and to include expanded
  parameters of tolerance

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Acknowledgement

• This study was funded by a grant from the
  University of Michigan Practice-Oriented Research
  Training (PORT) Program and the Department of
  Physical Medicine and Rehabilitation. The PORT
  Program is part of the Michigan Institute for
  Clinical and Health Research at the University of
  Michigan and supported by a grant from the
  National Institutes of Health Clinical and
  Translations Sciences Award (UL1RR024986).