People With Brain Injuries Heal Faster If They Get Up And Get Moving
When Kate Klein began working as a nurse in the Cleveland Clinic's Neurointensive Care Unit, one of the first things she noticed was that her patients spent a lot of time in bed. She knew patients with other injuries benefitted from getting up and moving early on, and she wondered why not patients with brain injuries.
"I asked myself that question. I asked my colleagues that question," Klein says. "Why aren't these patients getting out of bed? Is there something unique about patients with neurologic injury?"
Doctors have long encouraged their surgical patients to get out of bed as soon as it's safe to do so. Movement increases circulation, reduces swelling, inflammation and the risk of blood clots, and it speeds healing.
But that wasn't the thinking with brain injuries, explains Edward Manno, director of the Neurointensive Care Unit at the Cleveland Clinic and one of the neurologists who works with Klein. "The predominant thinking was that rest was better suited for the brain," Manno says.
Often the damaged brain is susceptible to lack of blood flow. Increased activity may make things worse if initiated too quickly, Manno says. "So many of us thought for quite some time that we needed to put the brain to rest after the initial insult of stroke or other neurologic injury."
Nancy Albert, Kate Klein and Nancy Kaser collaborated on a study of early mobility for patients with brain injuries.
But some doctors, including Manno, suspected patients with brain injuries could benefit from getting out of bed sooner. They just didn't have any proof.
Although plenty of research had been done on early mobilization of patients with other injuries, Klein discovered that no one had actually studied whether it was safe or beneficial for patients with brain injuries caused by seizures, stroke or head trauma to start rehabilitation right away. So she designed a study of her own.
Over the course of a year, Klein tracked more than 600 patients with brain injury, getting more than half of them up and out of bed as early as the first day they were admitted to the ICU. What she found was that getting up and moving had clear benefits. Patients who started their rehabilitation earlier spent less time in the ICU and less time in the hospital. "They have less pressure ulcers, less infections and spend less time on the ventilator if they need ventilator therapy," says Klein. And most say they feel a lot better.
One of the barriers to getting patients with brain injury up is how difficult it is. It took two nurses more than half an hour to get patient Patricia Weeden out of bed and into a chair to visit with her daughter. Weeden, 66, from Cleveland, has suffered severe seizures that damaged her brain. She's hooked to a ventilator, so she can't speak. And she's unable to sit, stand or walk on her own.
"It is difficult to get these patients up," explains Klein.
As a result of her study, the Cleveland Clinic has installed ceiling mounted lifts at each patient's bedside in the Neurointensive Care Unit. Nurses receive other equipment and training to make moving patients safer and easier.
And although it seems like a lot of effort for a few steps from bedside to chair, Klein says it represents huge progress for a patient like Weeden. The benefits may go beyond preventing bed sores or infections. Manno says it may also speed the recovery of the brain.
The brain rewires itself, explains Jeffrey Kleim, an associate professor of biomedical engineering at Arizona State University who studies what happens to the brain after injury.
"And it does this by forming new synapses, forming new connections," says Kleim. "The neural circuits begin to change and adapt, and that's how these new functions begin to emerge in the remaining brain areas."
That neuroplasticity has been shown to be heightened immediately after injury in studies with animals. If the same is true in humans, the sooner patients get up and engage their brains the better their chances of recovery.
Kleim says much of the animal research has been focused on finding ways to jumpstart the rewiring process with drugs or electrical stimulation. But in people, he says, there is a much simpler way to drive the recovery process.
By getting patients up and out of bed early, even taking them outside, Klein and Manno say they are attempting to provide the sort of familiar experiences that are already known to stimulate the brain's natural rewiring process. Those experiences can be powerful, explains Klein, recalling a patient who suddenly began to speak after being outside for the first time.
"She was listening to the traffic, feeling the wind on her face, and then her sons came and they said 'Hi Mom,' and she looked up and said, 'Well, how are you doing?' Those were her first words," Klein says.
But as dramatic as those moments are, Manno says they only illustrate how much we still don't know about the recovery of the brain. For example, it's still unclear if all kinds of brain injuries can or should be treated the same.
"We are just scratching the surface here," says Manno. "There's a tremendous amount of work to be done in this area."
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Transcript
DAVID GREENE, HOST:
If you've just had surgery, one of the best things you can do to speed your recovery is to get up and get moving. Doctors have long encouraged surgical patients to get out of bed as soon as it's safe. But when it comes to injuries of the brain, rest has been seen as the best treatment - until now, that is. Today in Your Health, Gretchen Cuda Kroen looks at new research suggesting that getting out of bed early can help brain-injured patients as well.
GRETCHEN CUDA KROEN, BYLINE: When Kate Klein began working as a nurse in the Cleveland Clinic's Neurointensive Care Unit, one of the first things she noticed was that her patients spent a lot of time in bed. She knew patients with other injuries benefited from getting up and moving early, and she wondered, why not patients with brain injury, too?
KATE KLEIN: I asked myself that question, asked my colleagues that question - why aren't these patients getting out of bed? Is there something unique about patients with neurologic injury?
EDWARD MANNO: The predominant thinking prior to this study was that rest was better suited for the brain.
CUDA KROEN: Edward Manno is head of the Neurointensive Care Unit at the Cleveland Clinic, and one of the neurologists who works with Klein.
MANNO: Oftentimes damaged brain is susceptible to a lack of blood flow, and that increased activity may actually worsen the outcome if initiated too quickly. So many of us thought for quite some time that we needed to put the brain to rest after the initial insult of a stroke or some other type of neurologic injury.
CUDA KROEN: Despite this, many doctors, including Manno, suspected neurologic patients could actually benefit from getting out of bed sooner, they just didn't have any proof. Although plenty of research had been done on early mobilization of patients with other injuries, Klein discovered that no one had actually studied whether it was safe or beneficial for patients with brain injury to start rehabilitation right away, and so she designed a study of her own. Over the course of a year, Klein tracked more than 600 patients with brain injury, getting more than half of them up and out of bed as early as the first day they were admitted to the ICU. What she found was that getting up and moving had clear benefits.
KLEIN: We found that when patients actually get out of bed and progress in their rehabilitation early, they spend less time in the ICU, they spend less time in the hospital, they have less pressure ulcers, less infections, less time on the ventilator if they need ventilator therapy, and they also just feel a lot better.
UNIDENTIFIED NURSE #1: All right, Patricia, we're going to work at sitting at the edge of the bed. Walk your legs over towards Nathan.
UNIDENTIFIED NURSE #2: So bring them towards me. So let's start with your right leg first.
UNIDENTIFIED NURSE #1: Good. Now your left leg.
CUDA KROEN: Two nurses are helping Patricia Weeden get out of bed. Severe seizures have damaged her brain. She's hooked to a ventilator, so she can't speak, and she's unable to sit, stand or walk on her own.
UNIDENTIFIED NURSE #2: So on three. You ready? Here we go. Keep your eyes open. One, two, three.
CUDA KROEN: One of the barriers to getting patients like Patricia up and moving is how difficult it is.
UNIDENTIFIED NURSE #2: Stand up tall.
CUDA KROEN: It takes more than half an hour and two nurses to sit her up and then guide her to a chair where she'll sit and visit with her daughter.
UNIDENTIFIED NURSE #2: Let's just stand here for a little bit. Put some weight through your legs. There you go.
UNIDENTIFIED NURSE #1: There, that's much better.
KLEIN: It is difficult to get these patients up, so nurses are continually challenged with getting patients out of bed and having the proper equipment and resources to be able to get patients out of bed.
CUDA KROEN: As a result of her study, ceiling-mounted lifts were installed at each patient bedside, and nurses receive training and other equipment to make moving patients safer and easier. And although it seems like a lot of effort for a few steps from bedside to chair, Klein says it represents huge progress for a patient like Patricia. And the benefits may go beyond preventing bedsores or infections. Dr. Manno says they may also speed the recovery of the brain.
MANNO: Neurologic patients have many of the same medical issues that medical and surgical patients have. The concern was that the neurological aspect may limit their mobility. And I think what we're starting to show is that's not actually the case, that in fact, early mobility helps both not just with the medical issues, but with the neurological aspect also.
CUDA KROEN: The basis for this is something called brain plasticity - the ability of the brain to compensate for areas that become damaged. Jeffrey Kleim is a professor of biomedical engineering at Arizona State University, where he studies what happens to the brain after injury.
JEFFREY KLEIM: It rewires itself, and it does this by forming new synapses, forming new connections. The neural circuits begin to change and adapt. And that's how these new functions begin to emerge in remaining brain areas.
CUDA KROEN: The plasticity of the brain - its ability to rewire itself - has been shown to be heightened immediately after injury in studies with animals. If the same is true in humans, the sooner patients get up and engage their brains, the better their chances of recovery. Kleim says much of the animal research has been focused on finding ways to jumpstart the rewiring process with drugs or electrical shocks. But in people, there's a much simpler way to drive the recovery process.
KLEIM: The actual behavioral experience is one of the most powerful factors that can drive brain plasticity, and there's a century of evidence that that's true.
CUDA KROEN: But by getting patients up and out of bed early, even taking them outside, Kate Klein and Edward Manno say they're attempting to provide the sort of familiar experiences that are already well-known to stimulate the brain's natural rewiring process. Those experiences can be powerful, explains Klein, recalling a patient who suddenly began to speak after being outside for the first time.
KLEIN: And you could almost see that what was familiar was starting to come back to her, that she was listening to that traffic, feeling that wind on her face. And then her sons came and she looked over at her sons, and they said, hi, Mom. And she looked up and she said, well, how are you doing? Those were her first words.
CUDA KROEN: But as dramatic as those moments are, Manno says they only illustrate just how much we still don't know about the recovery of the brain. For example, it's still unclear if all kinds of brain injuries can be treated the same.
MANNO: We are just scratching the surface here on this, and this is, I think, really just pioneering work, but there's a tremendous amount of work to be done in this area.
CUDA KROEN: Klein's study was published in April, and her findings have already changed the way patients in the Cleveland Clinic's Neurological Intensive Care Unit are managed. Her hope is that others will follow suit and that one day, getting patients with brain injury up and moving will be the rule rather than the exception. For NPR News, I'm Gretchen Cuda Kroen. Transcript provided by NPR, Copyright NPR.
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