Early mobilization after stroke has been proven to be beneficial in recovery. This early mobilization involves exercises that focus on functional mobility, like rolling over, sitting, standing and eventually walking.
Early mobilization that begins as early as 24 hours after stroke has been shown to improve both physical function and recovery of the brain. In this article, we look at the changes the brain undergoes in the critical period immediately following a stroke and the types of impairments that can result. We will also discuss types of early mobility training that can optimize recovery after a stroke and the benefits of early mobilization.
Table of Contents:
- Brain changes and recovery
- Areas of impairment from stroke
- Types of early mobilization after stroke
- Equipment for stroke rehabilitation
- Barriers to participating in stroke rehabilitation
- Reduction of harms from bed rest
- Benefits of early mobilization
- Risks to mobilization
- Where does early mobilization happen
- Summary
Brain Changes and Recovery
There is a sensitive and critical period of time in the first six months following a stroke where the brain is undergoing recovery and remodeling. There are benefits to early mobilization during this time precisely because of the numerous changes occurring in the brain on a chemical and structural level.
Exercise can actually help with this recovery and can enhance a process called neuroplasticity.
Neuroplasticity is characterized as the ability of the central nervous system to undergo structural and functional changes with new experiences.
Research has recommended starting mobility as early as 24 hours after an injury to the brain, and starting a rehabilitation program in the first two weeks after the injury.[i] Receiving early mobility training in a rehabilitation setting will help to optimize an individual’s recovery after stroke.
It leads to improved functional mobility and functional independence. As for the brain, it promotes decreased volume of injury while also promoting neurogenesis (growth and sprouting of neurons).
A stroke is characterized as an injury to the brain related to blood flow. It can occur as ischemic (ie. a clot in a blood vessel in the brain), or hemorrhagic (ie. bleeding in the brain, which may be caused by a damaged blood vessel).
Cortical reorganization occurs immediately after a stroke. To compensate for damaged areas of the brain, the brain adapts, and the surviving areas take over certain functions. The brain reorganizes itself by having the uninjured hemisphere of the brain help with executing the functions of the injured part of the brain.
After one to two weeks, the injured hemisphere of the brain increases activity and is able to start executing more normal functions. This type of recovery may happen most in the first three months.[ii]
Regeneration to the neurons (nerve cells) in the brain also occurs. In animal studies it is shown that after an injury to the brain, the axon and dendrite of a neuron will undergo sprouting and growth. Synaptogenesis, the creation of synapses or connections between neurons starts to happen three days after an injury, and peaks after seven to 14 days. To help provide assistance and nutrients to the growth of the neurons, angiogenesis (growth of blood vessels) starts at 10 days after injury.[iii]
The brain also releases Brain Derived Neurotropic Factor (BDNF). It is a growth factor that promotes neurogenesis (formation of new neurons), and it suppresses apoptosis (death of cells). On a molecular level, the release of BDNF is linked with neuroplasticity. This in turn helps on a functional level with relearning motor skills. The effect is shown to be enhanced with aerobic exercise.[iv]
Areas of Impairment from Stroke
After a stroke, many systems of the body can be affected, and will benefit from intervention from various disciplines of a health care team. The team can include a physiotherapist, occupational therapist, speech language pathologist, nurses, neurologist, and physiatrist.
Some of the impairments that can occur are the following:
- Weakness in the arm and leg on one side
- Spasticity in the limbs
- Increased or decreased tone in the muscles
- Loss of balance
- Neglect – inattention to one side of the body
- Cognitive impairment
- Dysphagia – difficulty swallowing
- Dysarthria – difficulty speaking
- Aphasia – difficulty expressing and understanding language
- Decreased sensation
Types of Early Mobilization After Stroke
From a physiotherapist perspective, early mobilization involves exercises that focus on functional mobility. These early exercises focus on basic movements that have become challenging after a stroke. Exercises should start at the earliest 24 hours after the injury, once a patient is medically stable, and be completing daily exercises in the first two weeks.
Functional mobility in the early stages involves a gradual progression of activity tolerance starting with rolling in bed, and sitting. Depending on the severity of a stroke, an individual may gradually progress to standing, taking a few steps, and walking. These movements are usually taking place with trained professionals to provide appropriate and safe progression of activity. These basic movements can be difficult initially, but they can help with stabilizing an individual’s postural awareness, and improving activity tolerance.
Another form of exercise that will be performed are activities of daily living. An occupational therapist will focus on practicing these movements with an individual, and strategizing how to complete these tasks with the fewest compensations. These tasks can involve getting out of bed, getting dressed, brushing teeth and hair, getting yourself to the bathroom, cleaning yourself, and kitchen safety.
Spending time outside of bed by sitting up in a chair for most of the day time hours can improve activity tolerance and postural awareness. While sitting up in a wheelchair, an individual can also practice propelling themselves in the wheelchair by using their hands and feet, and even using their injured limbs if able. If an individual has some function in their injured limbs, it is beneficial to start attempting to use their limbs in meaningful ways, and attempting normal movements when able.
In order to show improvements in functional mobility, exercises should be repetitive, non-compensatory, intensive, and can also include constraint-induced therapy. These techniques in therapy involve teaching an individual to relearn how to use certain body parts by avoiding compensations early on, and forcing the limbs to attempt the movement. It is recommended to practice these exercises for 15 to 45-minute bouts of time, in 1-3 sessions per day.[ii]
Equipment for Stroke Rehabilitation
Various types of equipment can be helpful to progressing an individual through stages of mobility:
- Mechanical lift and sling
- Transfer pole
- Two-wheeled walker
- Rollator walker
- Quad cane
- Sam Hall turner
- Arm sling to stabilize a weak arm
- Large handle grips on utensils
Barriers to Participating in Stroke Rehabilitation
Taking part in therapy can allow a faster progression of functional mobility. However, there can be barriers that prevent or delay therapy from occurring. From the initial brain injury, an individual may be medically unstable which can affect their level of consciousness, drowsiness, and hemodynamic stability.
Having a stroke can cause emotional distress, as a stroke occurs without warning, and can change a person’s life dramatically. There can also be cognitive changes depending on the area of the brain affected, that can affect the way a person thinks, reasons, and makes decisions. All of the above can affect the ability for a person to participate fully in a therapy session.
Reduction of Harms from Bed Rest
Complete bed rest can be harmful to an individual. Early mobilization can help reduce the following issues:
- Infection
- Deep vein thrombosis
- Muscle wasting
- Decrease in cardiorespiratory function
- Pressure sores
- Atelectasis (closing of airways in the lungs)
- Longer length of stay in hospital
- Learned compensatory movements
- ICU-acquired weakness
- Muscle fiber change to fast-fatigable, and insulin-resistant fibers
- Formation of intramuscular fat
Benefits of Early Mobilization
Mobilizing early will improve the following:
- Range of motion of upper and lower body
- Strength of upper and lower body
- Pulmonary function
- Quality of life
- Functional mobility
- Functional independence
- Ability to walk at dischargev
Risks to Mobilization
As an individual starts to mobilize in hospital, they may not be medically stable yet. A team of medical professionals will be monitoring an individual’s status to make the most appropriate decision in regards to when to start mobilizing.
Research shows there is more risk with mobility prior to 24 hours from a brain injury. When starting to mobilize, it is possible the movement can cause the blood pressure to raise or lower, and that is why vital signs will be monitored closely during this time.
There can also be a risk of falls due to changes in muscular strength, levels of consciousness, and cognition. Working with experts of mobility, like a physiotherapist and occupational therapist, can help prevent chances of falls and allow safe mobility.
Where Does Early Mobilization Happen
After a stroke, an individual will be at a hospital. They may start their mobility in an intensive care unit (ICU), or be sent to a stroke unit to complete rehabilitation therapy.
Once the hospital stay is complete, therapy should continue at an outpatient or private clinic, as neuroplasticity can continue to make changes to the body and brain over several years.
Summary
Early mobilization is supported in best practice guidelines for individuals who have a stroke, as it is proven to cause beneficial outcomes in functional recovery.[vi] There are changes that occur in the brain immediately after a stroke, and by implementing intervention early it can positively affect the recovery of the brain and the brain’s output for motor control.
There are different forms of early mobility a person can participate in depending on the severity and types of impairments acquired. Safe progressions of mobility can be achieved with the assistance of a therapist and equipment.
By participating in mobility, an individual can improve their quality of life, and also reduce harmful outcomes from bed rest. Ask us about our stroke rehabilitation programs to learn more about recovery beyond the hospital.
References
[i] Coleman ER, Moudgal R, Lang K, Hyacinth HI, Awosika OO, Kissela BM, Feng W. Early Rehabilitation After Stroke: a Narrative Review. Curr Atheroscler Rep. 2017 Nov 7;19(12):59. doi: 10.1007/s11883-017-0686-6. PMID: 29116473; PMCID: PMC5802378.
[ii] Bernhardt, J. et al. (2015) ‘Early mobilization after stroke’, Stroke, 46(4), pp. 1141–1146. doi:10.1161/strokeaha.114.007434.
[iii] Mariana de Aquino Miranda, J., Mendes Borges, V., Bazan, R., José Luvizutto, G., & Sabrysna Morais Shinosaki, J. (2021). Early mobilization in acute stroke phase: a systematic review. Topics in Stroke Rehabilitation, 30(2), 157–168. https://doi.org/10.1080/10749357.2021.2008595
[iv] Mang CS, Campbell KL, Ross CJ, Boyd LA. Promoting neuroplasticity for motor rehabilitation after stroke: considering the effects of aerobic exercise and genetic variation on brain-derived neurotrophic factor. Phys Ther. 2013 Dec;93(12):1707-16. doi: 10.2522/ptj.20130053. Epub 2013 Aug 1. PMID: 23907078; PMCID: PMC3870490.
[v] Alamri MS, Waked IS, Amin FM, Al-Quliti KW, Manzar MD. Effectiveness of an early mobility protocol for stroke patients in Intensive Care Unit. Neurosciences (Riyadh). 2019 Apr;24(2):81-88. doi: 10.17712/nsj.2019.2.20180004. PMID: 31056538; PMCID: PMC8015460.
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