Safety and Feasibility of an Early Mobilization Program for Patients With Aneurysmal Subarachnoid Hemorrhage

Design Overview

A retrospective study was conducted to examine the safety and feasibility of an early mobilization program for patients with aneurysmal SAH.

Setting and Participants

Patients admitted to the neurosurgical ICU at the Capital Health Regional Medical Center between January 2011 and May 2011 with a diagnosis of SAH were included in the study. The diagnosis of SAH was confirmed from computed tomography scans or xanthochromia of the cerebrospinal fluid. Patients were excluded if they were younger than 18 years of age, were admitted more than 14 days after SAH onset, care was withdrawn, or the SAH was determined to be caused by trauma or arteriovenous malformation. Aneurysmal SAH was confirmed by intra-arterial digital subtraction angiography.

Patients included in the study received transcranial Doppler (TCD) ultrasonography at least daily. The middle cerebral artery (MCA) mean flow velocity (MFV) and Lindegaard ratio (mean MCA velocity/mean internal carotid artery velocity) were calculated from TCD ultrasonography and used as a predictor for the development of DCI.^30–32 Continuous electroencephalography was conducted on patients in the study but did not preclude participation in the early mobilization program unless there was evidence of ischemia or seizure. Likewise, mechanical ventilation, external ventricular or lumbar drains, and arterial lines did not preclude patients from participating in the study.

Early Mobilization Program

The criteria to participate in the early mobilization program were derived from an early mobilization protocol for patients on mechanical ventilation in the ICU¹⁸ and modified for patients with aneurysmal SAH (Appendix 1). The criteria focused on ensuring neurologic and physiologic stability prior to the initiation of early mobilization program sessions. Preventing DCI and elevated ICP while maintaining adequate CPP are major components in the management of patients with aneurysmal SAH.²⁴ Because the effects of early mobilization on patients with aneurysmal SAH were unknown, participation in the early mobilization program was limited to patients at lower risk for the development of complications. Patients meeting the criteria for participation had a lower risk for DCI (Lindegaard ratio ≤3.0, MCA MFV ≤120 cm/s),^30–32 adequate CPP (mean arterial pressure [MAP] ≥80 and ≤110 mm Hg),²⁴ and normal ICP (≤15 mm Hg).²⁴

Patients identified for the study were assessed daily by a physical therapist or an occupational therapist, or both, to determine whether criteria were met to participate in the early mobilization program. Patients not meeting the criteria to participate in the early mobilization program were reassessed the following day. Early mobilization program sessions were conducted by the physical therapist or occupational therapist and lasted from 30 to 60 minutes, depending on patient tolerance. Patient participation in the early mobilization program was discussed daily with the multidisciplinary neurocritical care team, which consisted of neurosurgeons, intensivists, nurses, respiratory therapists, physical therapists, and occupational therapists. Neurologic presentation and physiologic stability were monitored during the early mobilization program sessions. Adverse events (Appendix 2) were similar to the participation criteria with the exception that the MAP threshold was set at 10 mm Hg above and below the participation criteria range because of the MAP variability associated with activity and positional changes. If an adverse event occurred during the session, the session was terminated. The physical therapist and occupational therapist documented in the medical record their intervention and adverse events that occurred during the session.

Early mobilization program sessions focused on positioning, education, functional training, and therapeutic exercise in the supine, sitting, standing, and walking positions (Tab. 1). Initially, functional training in the supine position consisted of bed mobility training and the transition in patient position from supine to with the head of bed elevated 30 degrees. When physiologic stability and patient tolerance were achieved in the head-of-bed 30-degree position, the patient transferred to sitting on the edge of the bed. Once physiologic stability and patient tolerance were achieved in a sitting position, the patient performed transfer, balance, posture, and activity of daily living (ADL) training as determined appropriate by the physical therapist or occupational therapist. During the supine and sitting phases of the early mobilization program, patients received active or passive range of motion, or both, to the following joints and motions as determined appropriate by the physical therapist or occupational therapist: glenohumeral flexion, elbow flexion and extension, wrist flexion and extension, finger flexion and extension, hip flexion, hip abduction and adduction, knee flexion and extension, and ankle dorsiflexion and plantar flexion.

After seated training activities were completed and as long as the patient remained physiologically stable and tolerant, the patient transferred to the standing position. Patients unable to actively participate in transferring to a standing position were transferred out of bed with a mechanical lift until they were able to actively assist the therapist. Patients able to participate in transferring to a standing position received standing balance, posture, and ADL training as determined appropriate by the physical therapist or occupational therapist. After standing training activities were completed and as long as the patient remained physiologically stable and tolerant, the patient was either transferred to a bedside chair using a stand-pivot technique or received gait or ADL training from the physical therapist or occupational therapist. Time spent sitting out of bed was encouraged as long as the patient remained physiologically stable and tolerant. Patients transferred back to bed with assistance from the physical therapist, occupational therapist, or nurse.

Outcome Measures

Primary outcomes of the study were the safety and feasibility of patient participation in the early mobilization program. Safety was measured by the quantity and type of adverse events that occurred during early mobilization program sessions and the 30-day mortality rate. The feasibility of patient participation was measured by the following: early mobilization program sessions attempted, sessions where criteria to participate were met, sessions where criteria to participate were not met, and reasons why patients did not meet participation criteria. Secondary outcomes included the following: type of interventions utilized during sessions, number of sessions that included out-of-bed activity and walking ≥15.24 m (50 ft), average time from admission to out-of-bed activity and walking ≥15.24 m, Barthel Index (BI)³³ at discharge, and discharge destination from the acute hospital.

Data Analysis

Data were collected from retrospective chart review by 3 investigators (B.F.O., L.E.S., and M.L.A.). Microsoft Excel software (Microsoft Office 2010, Microsoft Corporation, Redmond, Washington) was used for data collection and analysis. Descriptive statistics are represented as number (percentages) and means (standard deviations) unless otherwise specified.