Early Physiotherapy in the Neurointensive Care Unit - Passive Physiotherapy Interventions

Abstract: Background: In critically ill patients, treated in the neurointensive care unit (NICU) because of severe brain injury or stroke, physical activities have been restricted to a minimum due to the potential risks of complications and adverse events. Nevertheless, passive physiotherapy treatments are widely used without conclusive evidence for their safety. Aim: The overall aim of this thesis was to investigate if three different passive physiotherapy interventions i.e. prone position (PP), passive range of motion (passive-ROM) and continuous passive motion (CPM), were safe to use in patients that are critically ill due to severe brain injury or stroke when admitted to a NICU and to investigate the respiratory and circulatory effects of these interventions. Methods: This thesis consists of four different quantitative research papers. Paper I investigated the effect of PP on lung oxygenation as well as the intracranial and systemic haemodynamic variables before, during and after PP. Paper II investigated the intracranial, cerebrovascular and systemic haemodynamics before, during and after a session of passive-ROM as performed in clinical practice. Paper III studied peripheral blood flow velocity (PBFV) and resistance index (RI) before, directly after and after a passive-ROM intervention. In paper II and III a healthy control group matched for age and sex was also included. Paper IV studied intracranial and systemic haemodynamics before, during and after a session of 20 minutes of CPM with a bedcycle ergometer. Main results: I. PP enhanced oxygenation without any significant changes in intracranial pressure (ICP), cerebral perfusion pressure (CPP) or blood pressure (BP) while heart rate (HR) increased. II. During passive-ROM CPP, BP and HR did not change significantly, while ICP decreased after passive-ROM. Furthermore, no significant changes in cerebral blood flow velocity (CBFV) or pulsatility index (PI) were noted. In the healthy control group a significantly higher BP was found before the intervention, but no other significant results were noted. III. Passive-ROM interventions did not significantly affect PBFV or RI. When comparing the patient group with the control group in paper II and III, a significantly higher PI and PBFV and a lower RI were noted in the patient group. IV. CPM did not affect ICP but significantly increased BP and stroke volume (SV) during the exercise. Furthermore, cardiac output, SV, BP and CPP were increased during versus after the intervention. Conclusion: Prone position, passive-ROM and CPM are safe to use in critically ill patients, suffering from brain injuries or stroke treated in the NICU, since the intracranial and systemic haemodynamic responses are small. PP increased the oxygenation in this patient group. Keywords: physiotherapy, brain injury, stroke, intensive care unit, prone position, range of motion, continuous passive motion, intracranial pressure, cerebral perfusion pressure, haemodynamics

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