Effectiveness of an early mobility protocol for stroke patients in Intensive Care Unit

Study design

A single group pretest-posttest design was used.

Setting and sample

Seventy patients were screened for eligibility, of which 62 fulfilled the inclusion criteria, 2 patients died and their data were not used in the statistical analysis. Sixty patients with confirmed stroke (infarct or intracerebral hemorrhage) who were admitted to the ICUs in general hospitals in Riyadh, Kingdom of Saudi Arabia within 24 hours of stroke onset participated in this study, during October and December 2016. Patient inclusion criteria included an age of 40-60 years; because the muscle strength is affected by age, admitted to the ICU within 24 hours and without lower limb motion limitations. Exclusion criteria were hemodynamic instability, and any muscle weakness. The contraindications for initiating early mobility were, mean arterial pressure less than 65 mmHg, heart rate less than 60/min or above 120/min, respiratory rate less 10/min or above 32/min, and pulse oximetry less than 90%, insecure airway device or difficult airway, falls, removal of endotracheal tubes (ETT), removal or dysfunction of intravascular catheters, removal of catheters or tubes and cardiac arrest.

Ethical considerations

The Declaration of Helsinki principles were followed in this research; the ethical approval was obtained under the number 64/52362, 21/12/1437. Informed consent was obtained from all patients or their nominated representatives.

Measurements/Instruments. Pulmonary functions tests (PFTs)

Pulmonary function tests are a group of tests that evaluate the capacity of the lung.25 Zan-680 Ergospiro Ergospirometry System was used to measure pulmonary functions; Forced Vital Capacity (FVC) and Forced Expiratory Volume 1 (FEV1). These tests were carried out after cessation of a mechanical ventilator. Measurements were repeated after ten days of treatment.

Measurement of muscle strength

A hand-held dynamometer, small enough to hold in one hand and quickly read, was determined to be sensitive in detecting muscle strength reduction in the critically ill. The device had a liquid crystal display screen and 6 function buttons that controlled the menus and allowed option selection.26 Patients were instructed to apply maximum isometric contraction during dynamometry measurement. The dynamometer was placed perpendicular to the limb being measured. Biceps brachii, triceps, deltoid muscles in upper extremity and quadriceps, dorsiflexors, and plantar flexor muscles in lower extremities were evaluated bilaterally.23 The measurement was carried out before and after 10 days of treatment. The same examiner repeated the procedure and patients would rest for 1 minute between 2 consecutive trials. Patients tried 3 times for each muscle, and the best reading among 3 trials was taken. Minimal change in muscle strength was measured in units of weight such as pounds or kilograms.27

Quality of life measures. Barthel Index

Barthel Index is scale used to evaluate patient activity or recovery.15 It’s score ranges from 1 to 100. Patients were categorized by the following grades: 1) mildly recovered; score between 0-30; 2) moderately recovered; score between 31 and 60; and, 3) fully recovered; patients who scored between 61 and 100.

The modified Rankin Scale

The modified Rankin Scale is an ordinal scale ranging from zero (no disability) to 5 (severe disability), with a score of 6 allocated to those who die. A favorable outcome is defined as modified Rankin Scale scores of 0-2 (no or minimum disability), and poor outcomes were considered as scores of 3-6 (moderate or severe disability, or death.28 The scoring is illustrated in Figure 1.

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Figure 1

Progression of patients through the study.

Data collection/Procedure

Before each intervention, a nurse discussed the patient’s medical status and provided necessary medication and support for patient safety. A quick evaluation was carried out by a physical therapist before each physical therapy session to determine which category (Table 1) was appropriate for the patient’s condition.

All procedures were briefly described to patients, according to their level of consciousness, before the treatment protocol began. All techniques were conducted under the supervision of researchers. The protocol was stopped if any sign of hemodynamic instability was seen. Vital functions were regularly monitored during mobility activity. Therefore, a coordinated collaboration among members of the multidisciplinary health care team ensured proper care for and patient safety.29

Treatment modalities were administered depending on the stage of illness (patients were classified into 3 categories) (Table 1). Each session was of 60 to 90 minutes according to patient’s category. For category 1: 50 min of transcutaneous electrical muscle stimulation, 15 minutes of passive proprioceptive neuromuscular stimulation, 15 minutes of chest therapy and 5 to 10 minutes change position every 2 hours. For category 2: 30 minutes of transcutaneous electrical muscle stimulation, 15 minutes of chest therapy and 15 minutes of active exercises. For category 3: 15 minutes of chest therapy and 45 minutes of mobilizing and resistance exercises, as shown in Table 1.

Category 1

Acutely ill, unstable, requires life-support equipment such as mechanical ventilator. Modalities applied were passive proprioceptive neuromuscular facilitation, positioning, and splinting, transcutaneous electrical muscle stimulation, rolling side to side, and sitting balance. Application of these modalities required minimum level of patient cooperation, and involved minimal stress on the cardiorespiratory system.

Category 2

Stable cooperative patient but still on mechanical ventilation. Modalities applied were transferring patient, resistive muscle training, active walking with and without assistance.

Category 3

Cooperative patient, and weaning from mechanical ventilation. Modalities applied were resistive muscle training using pulleys, elastic bands, and weight belts, walking, deep breathing exercises, interventions to increase expiratory flow such as huffing and coughing, manually assisted cough.

Modalities descriptions. Proprioceptive neuromuscular facilitation

Proprioceptive neuromuscular facilitation was administered in the form of passive diagonal movement. Stretching techniques were applied for both upper and lower extremities. The frequency of Proprioceptive neuromuscular facilitation was 2 sets of 10 repetitions per each diagonal movement bilaterally.30

Positioning

The patient was positioned upright, supported to prevent soft tissue contractures, protect flaccid limbs, and avoid nerve compression, and skin breakdown. The rotations were carried out every 2 hours.31

Transcutaneous electrical muscle stimulation

Transcutaneous electrical muscle stimulation is a modality used to maintain muscle mass and strength in different conditions particularly in the ICU setting due to rapid loss of muscle mass. It is also used for immobile sedated patients. It was applied for 55 minutes, daily for the muscles of the lower extremity.32

Transfer & mobility technique

Early transfer and mobility techniques were started as soon as the patient’s medical condition was stable. For patients unable to ambulate, who have limiting weakness but can usually tolerate bed activities, therapeutic exercises were started. Then, they progressed to turn from side to side and sit on the edge of the bed. Trunk control was stimulated by applying sitting balance activities. When limb and trunk muscles strengthened, standing with a walker or assistance began. At first, standing was for short periods and then gradually increased. The patient was transferred to a chair and, time in the chair was increased gradually. Walking activities were started in place, i.e., weight shifting, and stepping in place. Walking re-education was encouraged when appropriate; distance and duration depended on the patient’s tolerance. The intervention was performed, once a day for 10 days or until patient discharged.33,34

Chest physical therapy

Chest or respiratory physical therapy was introduced to patients in the ICU to improve respiratory status. Chest physical therapy included percussion; vibration; suction; cough, and breathing exercises. Techniques were applied to increase inspiratory volume including deep breathing exercises, mobilization, incentive spirometry, and body positioning. Techniques were performed to increase expiratory flow such as huffing and coughing, and manually assisted cough.35

Data analysis

Statistical analysis was carried out using statistical package for the social sciences; SPSS Inc., Chicago, IL, USA, version 22. Differences were assumed significant at p-value <0.05. Continuous variables were described in terms of mean and standard deviation while categorical variables were described by frequencies (number of cases), and relative frequencies (percentages). Paired T-test was used to test the differences in (muscle strength, forced vital capacity, forced expiratory volume 1) between pre and post treatment. Wilcoxon signed-rank test was used to test the differences in QOL measures between pre and post treatment.