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Rigshospitalet - a part of Copenhagen University Hospital
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Early orthostatic exercise in patients with severe traumatic or acquired brain injury

Research output: Book/ReportPh.D. thesis

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Patients with acquired brain injury undergo extensive rehabilitation, which, depending on the severity and general clinical state, may start early. Studies have found a positive effect of starting rehabilitation as soon as possible in patients with severe traumatic brain injury. In contrast, patients with stroke are generally recommended to be cautious with mobilisation in the early phase due to results from the AVERT III trial. Previous trials have mostly included stroke patients or patients with mild injuries, whereas patients with severe acquired brain injuries are few.

As a starting point, we investigated the benefits and harms of early mobilisation in patients with severe acquired brain injury through a systematic review. In total, four trials were identified, assessed for risk of bias and analysed with meta-analysis and Trial Sequential Analysis. We found no evidence of a difference between early mobilisation compared with standard care measured at the end of intervention or the longest follow-up on outcomes such as death or poor functionality, serious adverse events, non-serious adverse events, or consciousness. We found evidence of no effect on the quality of life at the longest follow-up, albeit these trials only included patients with stroke.

As previous trials had primarily focused on stroke, we designed a feasibility trial for severe traumatic brain injury and included 38 patients. We wanted to assess the feasibility of conducting early mobilisation in an ERIGO® tilt-table. The trial showed that early mobilisation is feasible in trials in terms of including patients and completing the exercises. We observed no effects of early mobilisation versus standard care on a number of outcomes, but the trial lacked sufficient
power.

One of the arguments for avoiding head-up mobilisation is the potentially harmful effects of reducing cerebral blood flow if autoregulation fails. To examine dynamic cerebral autoregulation in patients before and during head-up tilt in the trial, we first did a study investigating the relative and absolute reliability of the non-invasive mean flow index (nMxa) in a healthy population. We analysed the recordings using three different variations of block sizes for calculating the nMxa. Here we found that the 3-second block sizes yielded fair reliability with smaller confidence intervals, standard error of the measurements, and limits of agreements than the 5- and 10-seconds block sizes. All indicated difficulties in determining changes in an individual patient.

Thirty-four of the 38 patients with traumatic brain injury from the feasibility trial, were measured with non-invasive mean arterial pressure and middle cerebral artery flow velocity at baseline, after two weeks, and after four weeks before and during head-up tilt. Although we lost many patients to follow-up and given the limits in the reproducibility of the autoregulation index, our analysis did not indicate that early orthostatic exercise affects the systemic or cerebral haemodynamic response to head-up tilt adversely. Head-up tilt does not protect against orthostatic reactions.
Original languageEnglish
Number of pages330
Publication statusPublished - 2020

Note re. dissertation

Hovedvejleder Kirsten Møller fra Afdeling for Intensivbehandling for Hjerne- og Nervesygdomme og Afdeling for Bedøvelse, Smerte og Respirationsstøtte. Vejleder Jesper Mehlsen fra Juliane Marie Centeret, Rigshospitalet. <br/>Forsvaret 30. oktober 2020.

ID: 62004113