Early Intensive Rehabilitation Research Articles

Early intensive rehabilitation reverses locomotor disruption, decrease brain inflammation and induces neuroplasticity following experimental Cerebral Palsy

BackgroundCerebral Palsy (CP) is a major cause of motor and cognitive disability in children due to injury to the developing brain. Early intensive sensorimotor rehabilitation has been shown to change brain structure and reduce CP symptoms severity. We combined environmental enrichment (EE) and treadmill training (TT) to observe the effects of a one-week program of sensorimotor stimulation (EETT) in animals exposed to a CP model and explored possible mechanisms involved in the functional recovery. MethodsPregnant Wistar rats were injected with Lipopolysaccharide (LPS − 200 µg/kg) intraperitoneally at embryonic days 18 and 19. At P0, pups of both sexes were exposed to 20′ anoxia at 37 °C. From P2 to P21, hindlimbs were restricted for 16 h/day during the dark cycle. EETT lasted from P21 to P27. TT − 15 min/day at 7 cm/s. EE − 7 days in enriched cages with sensorimotor stimulus. Functional 3D kinematic gait analysis and locomotion were analyzed. At P28, brains were collected for ex-vivo MRI and histological assessment. Neurotrophins and key proteins involved in CNS function were assessed by western blotting. ResultsCP model caused gross and skilled locomotor disruption and altered CNS neurochemistry. EETT reversed locomotor dysfunction with minor effects over gait kinematics. EETT also decreased brain inflammation and glial activation, preserved myelination, upregulated BDNF signaling and modulated the expression of proteins involved in excitatory synaptic function in the brain and spinal cord. ConclusionsUsing this translational approach based on intensive sensorimotor rehabilitation, we highlight pathways engaged in the early developmental processes improving neurological recovery observed in CP.

Comparing motor development in children with hydrocephalus after treatment with ventriculoperitoneal shunt and endoscopic third ventriculostomy: a cross-sectional study.

Ventriculoperitoneal shunt insertion (VPSI) and endoscopic third ventriculostomy (ETV) are the major procedures for treating pediatric hydrocephalus. However, studies comparing motor development following the two treatments are limited. We aimed to determine motor development outcomes in children with hydrocephalus up to 2 years of age after undergoing VPSI or ETV, to identify which surgical approach yields better motor outcomes and may be more effective for Malawian children. This was a cross-sectional study where we recruited two groups of participants: one group consisted of children with hydrocephalus treated with VP shunt whilst the other group were treated with ETV, at least 6 months prior to this study. Participants were identified from the hospital records and were called to come for neurodevelopmental assessment using the Malawi Development Assessment Tool (MDAT). A total 152 children treated for hydrocephalus within an 18-month period met the inclusion criteria. Upon follow up and tracing, we recruited 25 children who had been treated: 12 had VPSI and 13 had ETV. MDAT revealed delays in both assessed motor domains: 19 out of the 25 children had delayed gross motor whilst 16 of 25 had delayed fine motor development. There was no significant difference between the shunted and the ETV groups. Children with hydrocephalus demonstrate delays in motor development six to 18 months after treatment with either VPSI or ETV. This may necessitate early and prolonged intensive rehabilitation to restore motor function after surgery. Long-term follow-up studies with bigger sample sizes are required to detect the effect of the two treatment approaches.

The Early Mobilization of Patients on Extracorporeal Membrane Oxygenation: A Systematic Review.

Patients on extracorporeal membrane oxygenation (ECMO) often require prolonged periods of bed rest owing to the severity of their illness. Care is also required to maintain the position and integrity of the ECMO cannula. However, they experience a range of effects due to prolonged bed rest. This systematic review examined the possible effects of the early mobilization in patients on ECMO. The database PUBMED was searched by using appropriate keywords: "rehabilitation", "mobilization", "ECMO" and "extracorporeal membrane oxygenation". The selection criteria for the article search were the following: (a) studies published in the last five years, (b) descriptive studies, (c) randomized studies, (d) published in the English language and (e) studies in adults. A total of 259 studies were found, 8 of which were finally selected. Most of the studies showed that early intensive physical rehabilitation related to a decrease in in-hospital stay and a reduction in the duration of mechanical ventilation and doses of vasopressors. In addition, improvements in the functional status and rate of mortality were observed along with a reduction in health care costs. Exercise training should be a fundamental part of the management of patients on ECMO.

Influence Of Baseline Comorbid Diseases on Major Depression and The Effect of Intensive Medical Treatment on Functional Mobility in Depressed Patients Compared with Those Without Depression

Objectives Somatic diseases, depression and functional mobility were examined in a follow-up study in geriatric patients. The first aim of the study was to assess the independent and moderator effects of baseline diseases on depression before adjustment by examining whether this influence will sustain or switch after adjustment. The second aim was to explore the differential treatment outcomes in functional mobility in depressed patients versus those with no depression. Methods A sample of n = 1,816 multimorbid patients consisting of n = 902 with a diagnosis of major depression and their counterparts n = 914 without depression were examined at two time points. They all underwent acute rehabilitation. Those who were diagnosed with major depression received an antidepressant and psychotherapy treatment. Depressive symptoms were recorded with the Geriatric Depression Scale. Functional mobility was measured using the Tinetti Test. Results We found that 431 patients (47%) were in partial remission at follow-up. The results yield a significant improvement in functional mobility in both groups as an effect of the intensive rehabilitation program. These findings support published findings highlighting an overall functional health enhancement owing to a combined medical rehabilitation, antidepressant and psychotherapeutic treatment as a result of early intensive rehabilitation for elderly patients with multiple medical conditions. The findings show that elderly patients with multiple chronic conditions benefit from intensive rehabilitation, psychotherapy and antidepressant treatment within three weeks of intensive stationary treatment. Results showed that baseline comorbid diseases (mainly focal neurologic deficits and coronary artery diseases) each act as risk factors for major depression before treatment. An intercept effect was unveiled between obesity and arterial hypertension that arises as risk factors for depression before adjustment. After adjustment, we found that baseline chronic conditions, specifically coronary artery disease, focal neurologic deficits, heart or valvular insufficiency, artificial valvular or pace maker and tumour diagnosis in respiratory organ each act as a potential risk factor for depression occurrence. The intercept effect erased after treatment. Functional health was increased significantly in both groups at follow-up. However, there was no difference in the increase of functional mobility (Tinetti Test) in non-depressed and depressed patients following the rehabilitation. Conclusion The results bolster up the conjecture that specific somatic diseases influence major depression before and after treatment and support an association between somatic diseases, depression, and functional health in elderly patients. In depressed and non-depressed patients, geriatric rehabilitation boosts functional mobility, which is crucial for the maintenance of autonomy in elderly patients. Major depression may hamper functional mobility rehabilitation’s outcome only if not well managed or overlooked.

Early Intensive Physical Rehabilitation Combined with a Protocolized Decannulation Process in Tracheostomized Survivors from Severe COVID-19 Pneumonia with Chronic Critical Illness.

(1) Background: Intensive care unit (ICU) survivors from severe COVID-19 acute respiratory distress syndrome (CARDS) with chronic critical illness (CCI) may be considered vast resource consumers with a poor prognosis. We hypothesized that a holistic approach combining an early intensive rehabilitation with a protocol of difficult weaning would improve patient outcomes (2) Methods: A single-center retrospective study in a five-bed post-ICU weaning and intensive rehabilitation center with a dedicated fitness room specifically equipped to safely deliver physical activity sessions in frail patients with CCI. (3) Results: Among 502 CARDS patients admitted to the ICU from March 2020 to March 2022, 50 consecutive tracheostomized patients were included in the program. After a median of 39 ICU days, 25 days of rehabilitation were needed to restore patients’ autonomy (ADL, from 0 to 6; p < 0.001), to significantly improve their aerobic capacity (6-min walking test distance, from 0 to 253 m; p < 0.001) and to reduce patients’ vulnerability (frailty score, from 7 to 3; p < 0.001) and hospital anxiety and depression scale (HADS, from 18 to 10; p < 0.001). Forty-eight decannulated patients (96%) were discharged home. (4) Conclusions: A protocolized weaning strategy combined with early intensive rehabilitation in a dedicated specialized center boosted the physical and mental recovery.

Intensive physical therapy after emergency laparotomy: Pilot phase of the Incidence of Complications following Emergency Abdominal surgery Get Exercising randomized controlled trial.

Postoperative pneumonia and delayed physical recovery are significant problems after emergency laparotomy. No randomized controlled trial has assessed the feasibility, safety, or effectiveness of intensive postoperative physical therapy in this high-risk acute population. The internal pilot phase of the Incidence of Complications after Emergency Abdominal Surgery: Get Exercising (ICEAGE) trial was a prospective, randomized controlled trial that evaluated the feasibility, safety, and clinical trial processes of providing intensive physical therapy immediately following emergency laparotomy. Fifty consecutive patients were recruited at the principal participating hospital and randomly assigned to standard-care or intensive physical therapy of twice daily coached breathing exercises for 2 days and 30 minutes of daily supervised rehabilitation over the first 5 postoperative days. Interventions were provided exactly as per protocol in 35% (78 of 221 patients) of planned treatment sessions. Main barriers to protocol delivery were physical therapist unavailability on weekends (59 of 221 patients [27%]), awaiting patient consent (18 of 99 patients [18%]), and patient fatigue (26 of 221 patients [12%]). Despite inhibitors to treatment delivery, the intervention group still received twice as many breathing exercise sessions and four times the amount of physical therapy over the first 5 postoperative days (23 minutes [interquartile range, 12-29 minutes] vs. 86 minutes [interquartile range, 53-121 minutes]; p < 0.001). One adverse event was reported from 78 rehabilitation sessions (1.3%), which resolved fully on cessation of activity without escalation of medical care. Intensive postoperative physical therapy can be delivered safely and successfully to patients in the first week after emergency laparotomy. The ICEAGE trial protocol resulted in intervention group participants receiving more coached breathing exercises and spending significantly more time physically active over the first 5 days after surgery compared with standard care. It was therefore recommended to progress into the multicenter phase of ICEAGE to definitively test the effect of intensive physical therapy to prevent pneumonia and improve physical recovery after emergency laparotomy. Therapeutic/Care Management; Level II.

Особенности раннего подключения речевого процессора у пациентов после кохлеарной имплантации

Hearing loss affects the entire course of a child’s development, especially if it occurred at an early age. At the same time, features of auditory, cognitive, and emotional-personal development are noted. Hearing loss limits social activity, communication, and psychoemotional comfort. The widespread spread of the disease presents a serious problem for public health. In the context of the spread of the new coronavirus infection COVID-19, the epidemiological picture in different regions and within them may change; in this regard, there are certain difficulties with hospitalization of patients, which are associated with an increased risk of morbidity and the collection of all the necessary analyses. To solve this problem, an early connection is used without patients being discharged from the hospital after surgery. Cochlear implantation followed by early intensive rehabilitation can allow patients to master speech, language, and social skills as soon as possible, which can be successfully used during a critical period when children master speech. The purpose of this article is to identify and compare the perceived advantages of early connection of the cochlear implantation system processor: early start of settings, allowing the child to have physical hearing, on the basis of which spontaneous oral speech will form naturally.

Effect of early intensive rehabilitation on the clinical outcomes of patients with acute stroke.

Intensive rehabilitation effectively improves physical functions in patients with acute stroke, but the frequency of intervention and its cost-effectiveness are poorly studied. This study aimed to examine the effect of early high-frequency rehabilitation intervention on inpatient outcomes and medical expenses of patients with stroke. The study retrospectively included 1759 patients with acute stroke admitted to the Kobe City Medical Center General Hospital between 2013 and 2016. Patients with a transient ischemic attack, subarachnoid hemorrhage, and those who underwent urgent surgery were excluded. Patients were divided into two groups according to the frequency of rehabilitation intervention: the high-frequency intervention group (>2 times/day, n=1105) and normal-frequency intervention group (<2 times/day, n=654). A modified Rankin scale score ≤2 at discharge, immobility-related complications and medical expenses were compared between the groups. The high-frequency intervention group had a significantly shorter time to first rehabilitation (median [interquartile range], 19.0 h [13.1-38.4] vs. 24.7 h [16.1-49.4], P < 0.001) and time to first mobilization (23.3 h [8.7-47.2] vs. 22.8 h [5.7-62.3], P=0.65) than the normal-frequency intervention group. Despite higher disease severity, the high-frequency intervention group exhibited favorable outcomes at discharge (modified Rankin scale, ≤2; adjusted odds ratio, 1.89; 95% confidence interval, 1.25-2.85; P=0.002). No significant differences were observed between the two groups concerning the rate of immobility-related complications and total medical expenses during hospitalization. High-frequency intervention was associated with improved outcomes and decreased medical expenses in patients with stroke. Our results may contribute to reducing medical expenses by increasing the efficiency of care delivery. Geriatr Gerontol Int 2021; 21: 623-628.

Evaluating the Benefits of Early Intensive Rehabilitation for Patients With Sepsis in the Medical Intensive Care Unit: A Retrospective Study

Purpose: To evaluate the benefits of early rehabilitation intervention for patients with sepsis in a medical intensive care unit (MICU) and to identify the factors associated with positive outcomes at discharge. Methods: A retrospective review of 97 electronic medical records of patients with sepsis admitted to 2 similar-sized MICU pods of an urban tertiary care hospital was conducted. Bivariate analyses were conducted to compare the sociodemographics, length of stay, mobility level, and discharge disposition of 47 patients who received early rehabilitation intervention in MICU pod 1, with 46 patients who received standard rehabilitation intervention in MICU pod 2. In addition, multivariate analysis of the entire sample was conducted to identify the factors associated with positive discharge outcomes. Results: Patients in pod 1 had significantly higher level of mobility at discharge (mean difference = 0.80, P = .009) and a better discharge disposition (λ2 = 25.05, df = 7, P &lt; .001) than those in pod 2. The positive outcomes of increased mobility and return to home at discharge were associated with rehabilitation intensity (F 1,91 = 52.30; P &lt; .001, b = 0.82) and rehabilitation initiation (adjusted odds ratio: 0.85, P = .039), respectively. Conclusion: These findings provide empirical support for the safety and benefits of providing early intensive rehabilitation for patients in the MICU with sepsis using a therapist-driven model of care.

Early Intensive Inpatient Rehabilitation for Children Undergoing Hemispherotomy

Background: Hemispherotomy is the treatment of choice for children with refractory epilepsy. Although hemiplegia, sensory and motor impairments result from this surgical procedure, seizure control is effective as well as anticonvulsant dose reduction. Description of functional gains after rehabilitation of these children are still incomplete. Aims: To evaluate the effects of an early intensive rehabilitation program in the gross motor function of lower limbs after 30, 90, 180 and 360 days of surgery for the treatment of epilepsy (hemispherotomy), and compare to historic controls. Materials and Methods: prospective and longitudinal case series, with historic controls. Fourteen out of sixteen children who underwent hemispherotomy from January 2012 to February 2013 received an early rehabilitation protocol (ERP). Functional assessment included the Berg Balance Scale (BBS), Fugl-Meyer Scale (FMS) lower limb subscale, and Gross Motor Function System of Classification (GMFCS), as well as the need of wheelchairs and walking aids. A historical group of 13 children who received a conventional rehabilitation protocol (CRP) was used as control. Results: FMS and BBS improved in ERP subjects until 6 months after surgery and reached a plateau. One year after hemispherotomy, all children in the ERP group could walk independently and had mild limitations to mobility whereas, among those in the CRP subjects, there was a higher prevalence of musculoskeletal deformities and severe gait restrictions. Conclusions: ERP promotes rapid functional recovery during one-year follow-up and, as compared to the CRP group, the average functional capacity of the ERP group was considerably higher. These data support the beneficial effects of a specific, individualized and early rehabilitation approach for such patients.

Early Intensive Multi-Faceted Rehabilitation in Stroke Patients: What is the Best Effective Rehabilitation Time?

Early Intensive Multi-Faceted Rehabilitation in Stroke Patients: What is the Best Effective Rehabilitation Time?

Early rehabilitation during extracorporeal membrane oxygenation has minimal impact on physiological parameters: A pilot randomised controlled trial

BackgroundPatients on extracorporeal membrane oxygenation (ECMO) often require prolonged periods of bed rest owing to their severity of illness along with the care required to maintain the position and integrity of the ECMO cannula. Many patients on ECMO receive passive exercises, and rehabilitation is often delayed owing to medical instability, with a high proportion of patients demonstrating severe muscle weakness. The physiological effects of an intensive rehabilitation program started early after ECMO commencement remain unknown. ObjectivesThe primary objective of this study was to describe the respiratory and haemodynamic effects of early intensive rehabilitation compared with standard care physiotherapy over a 7-d period in patients requiring ECMO. MethodsThis was a physiological substudy of a multicentre randomised controlled trial conducted in one tertiary referral hospital. Consecutive adult patients undergoing ECMO were recruited. Respiratory and haemodynamic parameters, along with ECMO settings, were recorded 30 min before and after each session and continuously during the session. In addition, the minimum and maximum values for these parameters were recorded outside of the rehabilitation or standard care sessions for each 24-h period over the 7 d. The number of minutes of exercise per session was recorded. ResultsFifteen patients (mean age = 51.5 ± standard deviation of 14.3 y, 80% men) received ECMO. There was no difference between the groups for any of the respiratory, haemodynamic, or ECMO parameters. The minimum and maximum values for each parameter were recorded outside of the rehabilitation or standard care sessions. The intensive rehabilitation group (n = 7) spent more time exercising per session than the standard care group (n = 8) (mean = 28.7 versus 4.2 min, p < 0.0001). Three patients (43%) in the intensive rehabilitation group versus none in the standard care group mobilised out of bed during ECMO. ConclusionsIn summary, early intensive rehabilitation of patients on ECMO had minimal effect on physiological parameters.

A randomized control trial of intensive aphasia therapy after acute stroke: The Very Early Rehabilitation for SpEech (VERSE) study.

BackgroundEffectiveness of early intensive aphasia rehabilitation after stroke is unknown. The Very Early Rehabilitation for SpEech trial (VERSE) aimed to determine whether intensive aphasia therapy, beginning within 14 days after stroke, improved communication recovery compared to usual care.MethodsProspective, randomized, single-blinded trial conducted at 17 acute-care hospitals across Australia/New Zealand from 2014 to 2018. Participants with aphasia following acute stroke were randomized to receive usual care (direct usual care aphasia therapy), or one of two higher intensity regimens (20 sessions of either non-prescribed (usual care-plus or prescribed (VERSE) direct aphasia therapy). The primary outcome was improvement of communication on the Western Aphasia Battery-Revised Aphasia Quotient (AQ) at 12 weeks after stroke. Our pre-planned intention to treat analysis combined high intensity groups for the primary outcome.FindingsAmong 13,654 acute stroke patients screened, 25% (3477) had aphasia, of whom 25% (866) were eligible and 246 randomized to usual care (n = 81; 33%), usual care-plus (n = 82; 33%) or VERSE (n = 83; 34%). At 12 weeks after stroke, the primary outcome was assessed in 217 participants (88%); 14 had died, 9 had withdrawn, and 6 were too unwell for assessment. Communication recovery was 50.3% (95% CI 45.7–54.8) in the high intensity group (n = 147) and 52.1% (95% CI 46.1–58.1) in the usual care group (n = 70; difference −1.8, 95% CI −8.7–5.0). There was no difference between groups in non-fatal or fatal adverse events (p = 0.72).InterpretationEarly, intensive aphasia therapy did not improve communication recovery within 12 weeks post stroke compared to usual care.

Early Intensive Rehabilitation for Patients with Traumatic Brain Injury: A Prospective Pilot Trial

To investigate the effects of early intensive rehabilitation management on the recovery of motor function and activities of daily living in patients with moderate traumatic brain injury. Eighty-seven patients (age range, 18-65 years) with traumatic brain injury that met the enrollment criteria were randomly divided into 2 groups. Group 1 received early and high-intensity rehabilitation management (from 7 days after injury, 7 d/wk, 4 times/d, 1 h/session) for 4 weeks; group 2 received ordinary rehabilitation (from 14 days after injury, 5 d/wk, 2 times/d, 1 h/session) for 4 weeks. The Fugl-Meyer Assessment (FMA, motor function) and Barthel Index (BI) were used to assess the daily living functional state before treatment, 3 months after injury, and 6 months after injury. The Glasgow Coma Scale (GCS) was used to assess outcomes 6 months after injury. Three months after rehabilitation, the FMA (motor function) score was significantly higher in the early intensive intervention group versus the control group (59.83 ± 11.87 vs. 44.56 ± 8.32, respectively; P < 0.05); no significant between-group differences were found in the GCS score or BI score (P > 0.05). Six months after rehabilitation, the FMA score and BI score were significantly higher in the early intensive intervention group versus the control group (FMA: 73.18 ± 16.55 vs. 57.86 ± 10.67, P < 0.01; BI: 87.17 ± 13.85 vs. 60.68 ± 11.98, P < 0.01, respectively). The GCS score was higher in the early intensive intervention group versus the control group (4.24 ± 0.91 vs. 3.43 ± 0.88, P<0.05, respectively) 6 months after injury. Early intensive rehabilitation management might be more beneficial for neurologic function and activities of daily living in patients with moderate traumatic brain injury.

The association between vitamin D levels and burn factors in different burn types.

BackgroundPatients with burns present with different clinical features depending on the types of burn injury and burn patients with lower levels of vitamin D have worse prognoses and more complications. The study aims to investigate the association between vitamin D levels and burn factors according to each burn type in relation to early intensive rehabilitation therapy initiated for inpatients with burns.MethodsIn this retrospective study, we enrolled 757 of 1716 inpatients who underwent rehabilitative therapy between May 2013 and April 2017. Burn types were divided into flame burn, electrical burn and other burns, including scalding, contact and chemical burns. Age, burned body surface area (BSA), wound healing time (WHT), length of hospital stay (LOS) and body mass index were analysed between vitamin D deficient and non-deficient patient groups using Student’s t-tests, or Mann-Whitney U test and among three burn types using one-way analysis of variance (ANOVA) or Kruskal-Wallis one-way ANOVA. The relationship between vitamin D levels and burn factors was evaluated using Pearson's or Spearman's correlation coefficient tests, and multiple linear regression analysis in different burn groups.ResultsIn total, 88.9% patients were vitamin D deficient, and these patients had a larger burned BSA (p = 0.015) and longer WHT and LOS (all p < 0.001) than non-deficient patients. Burned BSA, WHT and vitamin D levels showed significant differences in their mean values according to three burn types (all p < 0.001). WHT was a communal factor significantly associated with vitamin D levels in all three burn types (p < 0.05). The WHT cut-off points to predict vitamin D deficiency were 55 days for flame burn (p < 0.001) and 62.5 days for electrical burn (p = 0.001).ConclusionsWHT across all three burn types was a common factor associated with vitamin D levels for inpatients with burns who had undergone rehabilitative therapy. Electrical burn patients with vitamin D deficiency, even those with a low burned BSA percentage, showed prolonged wound healing over a two-month post-burn period. Independent of burned BSA, nutritional intervention concerning vitamin D in relation to burn wound healing should be considered to guide early initiation of intensive rehabilitation therapy.

NQPC-07 IMMEDIATE POSTOPERATIVE REHABILITATION FOR PATIENTS WITH NEWLY-DIAGNOSED GLIOMA

BACKGROUNDSImportance of early intensive rehabilitation is recently emphasized not only for Stroke Unit but for Intensive Care Unit. We have started such early comprehensive rehabilitation for patients after brain tumor surgery. Rehabilitation therapists were specially assigned to our brain surgery unit as members of the ward staffers. The purpose of this study is to show how this rehabilitation trial works for post-surgery patients with glioma.METHODSThirty-two patients with glioma (20 males and 12 females) who were admitted to our institution in the year of 2018 were included. Mean age was 61.8±13.3 years; glioblastoma was the major tumor type (24 patients). We retrospectively analyzed rehabilitation outcome focusing on improvement of the Functional Independence Measure (FIM) scores during hospitalization.RESULTSMean duration from surgery to the first rehabilitation intervention was 2.4±1.2 days, and mean hospital stay was 74.4±31.4days. Twenty patients were discharged to home (62 %) and 12 were transferred to other hospitals for convalescence. Motor, cognitive and total FIM scores were 41.0±22.2, 18.0±7.5, and 59.1±27.3 before surgery, whereas they were 61.4±28.6, 21.8±9.4, and 83.2±36.9, respectively, at discharge. Motor FIM items revealed more remarkable improvement than those of cognitive ones. Since starting the early intensive rehabilitation trial, patients with brain tumor have been systematically rehabilitated with an organized manner before and after surgery.CONCLUSIONEarly intensive rehabilitation for patients with brain tumor is recommended to be done by on-ward therapists who are assigned to work specially as members of the ward. Both motor and cognitive improvement is expected during hospitalization even in patients with malignant brain tumor.

Physical therapy in successful venoarterial extracorporeal membrane oxygenation bridge to orthotopic heart transplantation

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a temporary mechanical circulatory support system that may be used as a lifesaving therapy for patients in acute heart failure and as a bridge to definitive management. Physical therapy in these patients remains challenging, with limited protocols to guide practitioners. We describe a case of a 37-year-old gentleman who presented with familial cardiomyopathy and cardiogenic shock. Our patient underwent urgent peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) followed by successful heart transplantation. While on ECMO support he was enrolled in a physical therapy program that included the VitalGo Tilt Bed to improve lower body weight bearing while avoiding hip flexion and damage to the peripheral ECMO cannulae. The patient was discharged home expeditiously after heart transplant due to aggressive physical rehabilitation while on full VA-ECMO support. Early intensive physical rehabilitation is feasible and safe and may result in improved outcomes and expeditious discharge in VA ECMO patients. Protocol driven multidisciplinary physical therapy with a patient on femorally cannulated VA-ECMO retains the advantages of lower extremity peripheral cannulation while eliminating the risks of immobility. The new UNOS allocation system may result in a successful bridge to transplantation in patients on VA-ECMO due to the increased prioritization of this population to receive donor organs.

The Efficacy and Safety of Inpatient Rehabilitation Compared With Home Discharge After Hip or Knee Arthroplasty: A Meta-Analysis and Systematic Review

BackgroundTotal hip and knee arthroplasties (THKAs) are successful procedures in managing end-stage arthritis when nonoperative treatments fail. The immediate postoperative period is an important time for the body to recuperate and rehabilitate. Studies have shown that early intensive rehabilitation can enhance recovery. Rehabilitation can be provided as inpatient rehabilitation (IR) or discharge with home rehabilitation. These options have been studied, but literature on the efficacy and safety of IR compared to home discharge is scarce, and evidence is not well established. This meta-analysis aims to compare the efficacy and safety of IR to home discharge with rehabilitation after THKA. MethodsA multidatabase search was performed according to PRISMA guidelines. Data from studies assessing the efficacy and safety of IR and home as discharge destinations after THKA were extracted and analyzed. ResultsFifteen studies were included, consisting of 37,411 IR patients and 172,219 home discharge patients. These studies had heterogeneous reporting methods, with some conflicting results. There was no clinically significant difference in clinical outcomes between the groups. Readmission was nearly 5 times (odds ratio = 4.87, 95% confidence interval = 3.24-7.33, P < .001) and periprosthetic complications nearly 3 times (odds ratio = 2.82, 95% confidence interval: 1.54-5.24, P < .001) higher in IR patients than those discharged home after THKA. ConclusionAlthough IR is associated with higher risks of complications and readmissions, this may be because of patient selection bias in the clinical setting. Following THKA, it is safe to discharge patients to home with rehabilitation whenever possible. Evidence levelLevel II, Meta-analysis of heterogeneous studies.

Can in-reach multidisciplinary rehabilitation in the acute ward improve outcomes for critical care survivors? A pilot randomized controlled trial.

To assess the feasibility of in-reach rehabilitation for critical care survivors following discharge from the intensive care unit. To determine whether additional in-reach rehabilitation reduces hospital length-of-stay and improves outcomes in critical care survivors, compared with usual therapy. A total of 66 consecutively-admitted critical care survivors with an intensive care unit stay ≥ 5 days were enrolled in the study. Of these, 62 were included in the analyses. Pilot randomized control trial with blinded assessment at 6 and 12 months. The intervention group (n = 29) received in-reach rehabilitation in addition to usual ward therapy. The usual-care group (n = 33) received usual ward therapy. The primary outcome assessed was length-of-stay. Secondary outcomes included mobility, functional independence, psychological status and quality-of-life. The intervention group received more physiotherapy and occupational therapy sessions per week than the usual-care group (median = 8.2 vs 4.9, p < 0.001). Total length-of-stay was variable; while median values differed between the intervention and usual care groups (median 31 vs 41 days), this was not significant and the pilot study was not adequately powered (p = 0.57). No significant differences were observed in the secondary outcomes at hospital discharge, 6- or 12-month follow-ups. Provision of intensive early rehabilitation to intensive care unit survivors on the acute ward is feasible. A further trial is needed to draw conclusions on how this intervention affects length-of-stay and functional outcomes.

Statistical analysis plan (SAP) for the Very Early Rehabilitation in Speech (VERSE) after stroke trial: an international 3-arm clinical trial to determine the effectiveness of early, intensive, prescribed, direct aphasia therapy.

Background Limited evidence exists to support very early intensive aphasia rehabilitation after stroke. VERSE is a PROBE trial designed to determine whether two types of intensive aphasia therapy, beginning within 14 days of acute stroke, provide greater therapeutic and cost-effectiveness than usual care. Objective To publish the detailed statistical analysis plan for the VERSE trial prior to unblinding. This statistical analysis plan was based on the published and registered VERSE trial protocol and was developed by the blinded steering committee and management team, led by the trial statistician. This plan was developed using outcome measures and trial data collection forms. Results The VERSE statistical analysis plan is consistent with reporting standards for clinical trials and provides for clear and open reporting. Conclusions Publication of a statistical analysis plan serves to reduce potential trial reporting bias and outlines transparent pre-specified analyses. Australian New Zealand Clinical Trials Registry (ANZCTR) Registration number: ACTRN12613000776707; Universal Trial Number (UTN) is U1111-1145-4130.