Iwona Physio: Stroke recovery- early physiotherapy in intensive care

According to a new national guidelines for stroke, rehabilitation plays an important role in recovery. It highlights that the frequency of therapy must enable stroke patients to meet their rehabilitation goals and therapy should continue as long as patients are willing and capable of participating and showing measurable benefit from treatment.

The National Clinical Guideline for Stroke pays attention into an early mobilisation. Those who are medically stable but with difficulties to move soon after a stroke should be offered frequent, short, daily mobilisations (45 min) and it should start between 24 and 48 hours after a stroke.

A stroke unit must be capable of providing rehabilitation to all its patients, providing a specialist early supported discharge service, so stroke patients can continue their rehabilitation at home.

Commissioners are recommended to look for specialist rehabilitation services which meet the specific health, social and vocational needs of people with stroke of all ages. And they should commission services capable of delivering specialist rehabilitation in out-patient and community settings, in liaison with inpatient services.

Why earlier, more frequent, and higher dose of out-of-bed sitting, standing, and walking activities are consider to be more effective than previously thought?

The research ‘Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial’ answers to above question very well. It says that the very early mobilisation intervention significantly reduced the odds of a favourable outcome 3 months after stroke compared with lower dose usual care starting, on average, 5 h later.

The biological rationale underlying the potential for early out-of-bed training centres around three arguments: (1) that bed rest negatively affects the musculoskeletal, cardiovascular, respiratory, and immune systems,and might slow recovery; (2) that immobility-related complications are common early after stroke at a time when patients are very inactive; and (3) that there might be a narrow window of opportunity for brain plasticity and repair, and the optimum period for change could be early after stroke. Prompt start and more episodes of out-of-bed activity might therefore improve outcome.

Early Physiotherapy in intensive care	Positioning	· to reduce skin damage, limb swelling, shoulder pain or subluxation, and discomfort, · to maximise function · to maintain soft tissue length. · to reduce respiratory complications · avoid compromising hydration and nutrition. Recommendations Patients with acute stroke should have an initial specialist assessment for positioning as soon as possible and within 4 hours of arrival at hospital. Healthcare professionals responsible for the initial assessment of patients with acute stroke should be trained in how to position patients appropriately, taking into account the degree of their physical impairment after stroke When lying or sitting, patients with acute stroke should be positioned to minimise the risk of aspiration and other respiratory complications, shoulder pain and subluxation, contractures and skin pressure ulceration.
Early Physiotherapy in intensive care	Early mobilisation	· significantly reduced the odds of a favourable outcome 3 months after stroke compared with lower dose usual care starting, on average, 5 h later. Recommendations Patients with difficulty moving after stroke should be assessed as soon as possible within the first 24 hours of onset by an appropriately trained healthcare professional to determine the most appropriate and safe methods of transfer and mobilisation. Patients with difficulty moving early after stroke who are medically stable should be offered frequent, short daily mobilisations (sitting out of bed, standing or walking) by appropriately trained staff with access to appropriate equipment, typically beginning between 24 and 48 hours of stroke onset. Mobilisation within 24 hours of onset should only be for patients who require little or no assistance to mobilise.