Advancing Recovery Through Early Mobilization in Neuro Care

Neuro Pathways Podcast Series

Release Date: October 15, 2026
Expiration Date: October 14, 2027

Estimated Time of Completion: 30 minutes

Advancing Recovery Through Early Mobilization in Neuro Care

Natalie Lilly, PT, DPT
Adam Barron, MD

Description

Each podcast in the Neurological Institute series provides a brief, review of management strategies related to the topic.

Learning Objectives

• Review up to date and clinically pertinent topics related to neurological disease
• Discuss advances in the field of neurological diseases
• Describe options for the treatment and care of various neurological disease

Target Audience

Physicians and Advanced Practice providers in Family Practice, Internal Medicine & Subspecialties, Neurology, Nursing, Pediatrics, Psychology/Psychiatry, Radiology as well as Professors, Researchers, and Students.

Accreditation

In support of improving patient care, Cleveland Clinic Center for Continuing Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

CREDIT DESIGNATION

• American Medical Association (AMA)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.
• American Nurses Credentialing Center (ANCC)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 ANCC contact hours.
• Certificate of Participation
  A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.
• American Board of Surgery (ABS)
  Successful completion of this CME activity enables the learner to earn credit toward the CME requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Credit will be reported within 30 days of claiming credit.

Podcast Series Director

Andreas Alexopoulos, MD, MPH
Epilepsy Center

Additional Planner/Reviewer

Ari Newman, BSN

Faculty

Natalie Lilly, PT, DPT
Children’s Hospital, Main Campus

Adam Barron, MD
Cerebrovascular Center

Host

Glen Stevens, DO, PhD
Cleveland Clinic Brain Tumor and Neuro-Oncology Center

Agenda

Advancing Recovery Through Early Mobilization in Neuro Care

Natalie Lilly, PT, DPT
Adam Barron, MD

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

Glen Stevens, DO, PhD

All other individuals have indicated no relationship which, in the context of their involvement, could be perceived as a potential conflict of interest.

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

HOW TO OBTAIN AMA PRA Category 1 Credits™, ANCC Contact Hours, OR CERTIFICATE OF PARTICIPATION:

Go to: Neuro Pathways Podcast October 15, 2026 to log into myCME and begin the activity evaluation and print your certificate If you need assistance, contact the CME office at myCME@ccf.org.

Copyright ©2026 The Cleveland Clinic Foundation. All Rights Reserved.

Introduction:

Neuro Pathways, a Cleveland Clinic podcast exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Dr. Glen Stevens, DO, PhD:

Early mobilization is an important part of recovery for critically ill neurological patients. In Cleveland Clinic's neuro intensive care unit, physicians and rehabilitation specialists work together to help patients safely begin the recovery process as early as possible. In this episode of Neuro Pathways, we explore the importance of early mobilization for inpatient neuro intensive care patients and how early rehabilitation can support recovery and improve outcome. I'm your host, Glenn Stevens, neurologist, neuro-oncologist in Cleveland Clinic's Neurological Institute. And joining me today is Dr. Adam Barron, a neurologist within the Cerebrovascular Center at Cleveland Clinic, and Dr. Natalie Lilly, physical therapist at Cleveland Clinic. Adam and Natalie, welcome to Neuro Pathways.

Dr. Adam Barron, MD:

Thank you very much.

Dr. Natalie Lilly, PT, DPT:

Thank you.

Dr. Glen Stevens, DO, PhD:

So let's first start by having you guys introduce yourselves to our listeners, tell us where you trained, where you came from, and what you're doing here on a regular basis. And Natalie, we'll have you start.

Dr. Natalie Lilly, PT, DPT:

Sure. So I got my undergraduate from Indiana University and then I went to PT school at Ohio State. I was in North Carolina for a little bit before coming to the Cleveland Clinic, and I've been on our neuro floors for about four, four and a half years, and just recently been spending more time down in the neuro ICU.

Dr. Glen Stevens, DO, PhD:

And I'm sure Adam appreciates that.

Dr. Natalie Lilly, PT, DPT:

I don't know, sometimes.

Dr. Glen Stevens, DO, PhD:

Thanks.

Dr. Adam Barron, MD:

More help, the better.

Dr. Glen Stevens, DO, PhD:

Adam?

Dr. Adam Barron, MD:

I'm Adam Baron. I'm a neuro-intensivist at Cleveland Clinic. I did my medical school at the Medical College of Wisconsin. After that, I went and did neurology residency at the University of Pittsburgh, close by, but not quite in Cleveland at that time. I ended up going to the West Coast at University of California, San Francisco for a fellowship in critical care. And then I came here. I've been here for the past four years in the neuro ICU. I also serve as program director for our Neurocritical Care fellowship.

Dr. Glen Stevens, DO, PhD:

I don't want to overtake the podcast, but I have a son that went to IU and you must be very excited about the Football National Championship last year.

Dr. Natalie Lilly, PT, DPT:

I'm kind of torn. So I've grown up an Ohio State fan, so I've always been an OSU fan. But since I lived in Indiana, I had my degree from IU, but my brother went there and he was very excited.

Dr. Glen Stevens, DO, PhD:

Well, I want to make you jealous and tell you that my son and I went to the championship game in California, and it was unbelievable.

Dr. Natalie Lilly, PT, DPT:

I can only imagine.

Dr. Glen Stevens, DO, PhD:

Unbelievable. I've never been to a more fun sporting event in my life. So just a little commercial to you out there. If you've never been to one and you have a prize team, make the trip. Put it on the bucket list. So, mobilization. I was doing a little bit of reading, and I'm old, I was born in the 50s. And in 1950, if you had a heart attack, what was the prescription? Do you know? Bedrest. So, if you came into the hospital and you had a heart attack in 1950, you would have four to six weeks of bedrest. And I know you're probably shaking your head and you can't believe it and you're thinking, "Man, those guys didn't know what was going on back then." And the reality is they didn't know what was going on back then. It's an honest statement. But there was a lot of fear, and the fear was that the heart attack was injuring cardiac tissue and it was vulnerable. And if you were doing increased work and movement, you're increasing the pressure and you're going to blow out the heart, really, that you would have an aneurysm and you would pop the heart and you would die. This was really the thinking. Now at the same time, they would allow you to continue to smoke and you could do a lot of things that maybe necessarily weren't so good and not to let the secret out of the bag. But when I started here, physicians could still smoke in their office, which is hard to believe. And you wonder why sometimes people look at the medical profession and they go, "Well, you did this and you did that." But everybody's working with the best knowledge that we have at the time when we're there. And the discussion that we're having now is someone digs up at the old tape and they look at it 20 years from now, they'll go, "Why did they say to do that? Why did that make sense?" So we'll evolve and we'll learn and we'll do better as it goes, but it's kind of shocking, isn't it, as it goes through. So the intensive care unit scares a lot of people. There's really sick people in there. There's a lot of noise in there. There's bells, whistles, machines plugged into everything, tubes, lines. I hate to move somebody and pull the monitor out and that type of thing. So early mobilization, Natalie, what does it mean to you? Adam calls you up and says, Natalie, got a patient here, need to do some early mobilization with them. What does that mean?

Dr. Natalie Lilly, PT, DPT:

So for us from a PT standpoint, it's generally whenever the patient is medically stable and ready, we can get in there as soon as possible. There are very few lines that we aren't able to mobilize with someone. And obviously if they did have one of those lines, we would wait. But if someone is medically stable, there really are very few contraindications for us to mobilize.

Dr. Glen Stevens, DO, PhD:

And tell me how little that would be to how much that might be.

Dr. Natalie Lilly, PT, DPT:

Yeah, so it could be as little from someone just on their telemetry monitoring to someone who's on a ventilator. They could also be on continuous dialysis. They could have multiple lines, arterial lines and other things such as that. We've mobilized patients with up to four or five IVs with all of that going on as well. So it just kind of depends on. I mean, it's a lot of coordination between myself, our nursing staff, the doctors to make sure they're stable, and then also our rehab techs too. I couldn't do it without them. I definitely couldn't move someone with all of that by myself. So it's a lot of collaboration for sure.

Dr. Glen Stevens, DO, PhD:

So Adam, I show up in your intensive care unit. I'm laying there, I'm intubated, I've got central line in, I've got Guillain-Barre or something. You think, boy, I better get this in. Tell me what you do. Do you call Natalie? What do you do? What do you tell her?

Dr. Adam Barron, MD:

I mean, a standard part of our admission order set for all patients to ensure that we don't forget it is consults to physical therapy, occupational therapy, and speech therapy.

Dr. Glen Stevens, DO, PhD:

See how much she's smiling when you say that word PT?

Dr. Adam Barron, MD:

It's such a core part of the day-to-day care of a neurologically ill patient that we want to make sure we don't forget it. And so they're heavily involved from day one.

Dr. Glen Stevens, DO, PhD:

And how proscriptive are you with them?

Dr. Adam Barron, MD:

I'm going to say that my knowledge base doesn't allow me to be as prescriptive. These guys are the experts. They spend time in training learning how to do this, how to safely mobilize people, what is appropriate, what's not appropriate. I think the level of prescriptiveness I get is me ensuring that patients remain safe during physical therapy. I want all of our patients to be able to get physical therapy and where the medical team really comes in is ensuring that that is a reasonable thing to do and a safe thing to do for every patient.

Dr. Glen Stevens, DO, PhD:

I'd always tell the residents, "Talk to the nurses." No offense to the physicians.

Dr. Adam Barron, MD:

No, you're right.

Dr. Glen Stevens, DO, PhD:

I always say talk to the nurses. Because the nurses, the physicians come by and they do a drive by and they see the patients for a few minutes, but the nurse is there for eight hours, 12 hours looking at the patient, and I always say that's your best resource. So I imagine you do the same thing, right?

Dr. Natalie Lilly, PT, DPT:

Absolutely. We pretty much go downstairs in the morning and we round with all of the nurses, do a quick little round. How's the patient doing? Can you tell us? They get report on night shift right before round.

Dr. Glen Stevens, DO, PhD:

So every day you do this?

Dr. Natalie Lilly, PT, DPT:

Every day I do that.

Dr. Glen Stevens, DO, PhD:

Excellent.

Dr. Natalie Lilly, PT, DPT:

I mean, it's very quick and very brief, but a great way for us to know, okay, this person's ready for us or they didn't have a great night. Maybe we let them rest and we'll check in the afternoon or they've got a test or something going on today that it wouldn't be appropriate for, but they are definitely core in keeping us working with patients safely.

Dr. Glen Stevens, DO, PhD:

I guess that's where the physicians come in. It's all safety, right? It's all what can we do safely? And sometimes we don't know till we do something and we go, well. But I mean, as long as the intention is always in the correct direction and that we're always doing what we believe is in the best interest of the patient, negative things will happen. I mean, a line will come out. I mean, things will happen. Lines come out when you do nothing. Patient just moves and we'll pull a line out so these things will happen. But I love to hear that you guys are rounding because certainly when I trained, that was never happening. There was no all these huddles and things. Nobody ever heard the word huddle other than in football, the term huddle. Huddle didn't exist in a hospital, but now it's a ubiquitous term, right? Everywhere you have a huddle. We have a huddle all day long for everything. We huddle and we discuss, but that's a good thing. I'm not saying it's a negative thing at all. What's the interplay between the PT and the OT? Are the OT rounding in the morning as well? Because I know we don't have an OT here. I know you probably pushed them out, but what's the relationship with the PT and the OT?

Dr. Natalie Lilly, PT, DPT:

So we have a really good relationship. Kelly is the main OT down there and we usually all go down together, talk to the nurses and quickly see who's appropriate for today, who's not. We could have a really large list of patients that we have to navigate, and then we could also have a really small list of patients. And so we work really well together. We also collaborate. Sometimes I'll get a patient up and I'll be like, Kelly, they might be really impulsive. You should probably go in after me and see that patient and then you can help them back to bed so that we're helping patients get up even when you might be walking by and say, oh, that patient probably should not be up. They're really impulsive. But we collaborate really well so we can continue to promote mobility in that setting too.

Dr. Glen Stevens, DO, PhD:

Yeah. And of course, fall risk is always a concern and we're trying to decrease. I was reading a statistic somewhere that per year, about a million people fall in a hospital somewhere in the United States. A million people will fall a year. That's incredible, right? I mean, that's shocking. Now again, a lot of them won't have much of an injury at all, but if you have a million people falling, you're going to have some serious issues. And I'm sure that's independent of the lines and that type of thing or I guess certain conditions where you'll go, well, we got an ICP monitor and we're measuring the pressure in the brain. We got to be careful. We don't need to do this or that. Fall is probably one of the bigger concerns or risks, getting people. Tell me about the lift team you mentioned.

Dr. Natalie Lilly, PT, DPT:

So we do have a lift team here at the hospital. The HUC or a nurse can put in an order for a lift team to come and they will actually help lift a patient out of bed and into their chair. We don't use it as much on our service. We're really fortunate that we have ceiling lifts in our room, in our neuro ICU rooms, so we don't have to call them, but they definitely use it up on the regular nursing floors and step-down units.

Dr. Glen Stevens, DO, PhD:

So Adam, maybe you can talk on that a bit about the new. I'll jump ahead a little bit to the new Neurologic Institute building. Talk about the lifts in the intensive care unit there. Going to be there everywhere?

Dr. Adam Barron, MD:

Similarly, we have built-in ceiling lifts, which is important for our patient population, especially in mobility limited patients who still need to get up to a chair, still need to get up out of bed. That's an important part of the neuro ICU. I think the other major highlight that we're looking forward to is just the physical space of the building. One of the biggest limitations for our therapy teams in our current space is the size of the rooms, the hallways, what it takes to mobilize a patient with those devices. Even if we know it can be done safely, it can be challenging to pivot and turn and ambulate these patients down the hallways. We're looking forward to the larger hallway space, the larger rooms that are going to be more facile for these patients to get out of bed.

Dr. Glen Stevens, DO, PhD:

And so you guys, when we're talking intensive care, we're talking step-down and intensive care, or are we talking primarily intensive care?

Dr. Adam Barron, MD:

Primarily ICU is our experience, but these patients are also mobilized in the step-down units and have similar mobility difficulties. Of course, if a patient with stroke comes into the neuro ICU and a couple days later, they're at the point where they can go to a step-down unit. Their mobility issues haven't improved over that timeframe, and so they're still going to need that level of therapy out in the step-down units.

Dr. Glen Stevens, DO, PhD:

My understanding is there's going to be restrooms, bathrooms in the intensive care unit rooms. Is that right?

Dr. Natalie Lilly, PT, DPT:

That'll be a big plus. That'll be awesome. There are a lot of patients that ask to use the bathroom. We don't have them.

Dr. Adam Barron, MD:

And a lot of patients who that's an important part of occupational therapy in particular. There's a lot of grooming tasks and things like that that are important things to assess and understand as a patient who's getting ready to leave the hospital or leave the ICU. Having that available in our unit's going to be a great thing.

Dr. Glen Stevens, DO, PhD:

Yeah, and I'm sure just they've made it so that the lighting is... They're maximizing the amount of sunlight that comes in.

Dr. Natalie Lilly, PT, DPT:

That'll be great.

Dr. Glen Stevens, DO, PhD:

Visualization, point of view from the nurses so that they can see multiple patients at time to keep everybody safe, those types of things. Let's say he says, "Hey, go see that Stevens and start to do some mobilization with him, but he's a pretty delicate soul, so we really can't get him up and do stuff." Talk about just passive range of motion and that type of thing and how helpful it is or isn't.

Dr. Natalie Lilly, PT, DPT:

It's not something that we do often. I will say we'll do it with an appropriate patient, but any sort of movement in bed can be beneficial. We can start working on proprioceptive input to these patients as well as educating family members too on things that they might be able to do outside of our therapy sessions. We really like to focus on can we set this person up? Can we work on getting out of bed? If we can't, then yes, we'll go to passive range of motion and exercises in bed. But a lot of that I will then do once or twice and then educate family members who want to be hands-on because a lot of that will be beneficial if we can do it more throughout the day as well.

Dr. Glen Stevens, DO, PhD:

I let all my family secrets out on this podcast, and my wife had a knee replacement several months ago, and it's unbelievable with a therapist. I mean, again, I look back to my days when I was in training and if I was in participating or whatever in a knee replacement and what the recovery was afterwards, and now it's like you're back to the room and it's like, "All right, get up." "What do you mean get up?" Get up, walk to the bathroom." "What do you mean walk to the bathroom?" "No, you can do it." And you do, right? I mean, I think for so long we just think people are so breakable and it's going to be a problem when on the other side we're just completely off base and it's the other thing and it's the not doing that's the problem. And first day post-op, walk up these stairs. "What do you mean walk up the stairs? I just had a joint..." "Well, you can do it." And you do it, right? So I guess you have to be a little bit of a drill sergeant-

Dr. Natalie Lilly, PT, DPT:

Sometimes.

Dr. Glen Stevens, DO, PhD:

... is what I'm getting to.

Dr. Natalie Lilly, PT, DPT:

You have to be sometimes.

Dr. Glen Stevens, DO, PhD:

In a nice way.

Dr. Natalie Lilly, PT, DPT:

I do get asked that question. A lot of times after spine surgery or something. "I just had surgery yesterday." "Well, we have to get up, we have to mobilize." Every day you spend in bed is another couple of days of recovery for you. So it's very important.

Dr. Glen Stevens, DO, PhD:

Yeah. It's just so different from when I trained and what the teaching was and the understanding was, well, you got to rest and take it easy for a while. And now it's move, move, move. I mean, for everything, say even I see the spine patients going down the hallway with a walker or holding somebody's hand. I mean, they're just right up in it because we understand it's good. It's good for the bone density, good for the muscles, good for DVTs, good for everything.

Dr. Adam Barron, MD:

To that point, a lot of what we've seen in general ICU complications, some of the most common complications we see are things like pressure injuries, DVTs, contractures, things that happen when people are in bed for a prolonged period of time with limited mobility. All that is helped by early mobilization and ambulation. And sure, nobody wants to walk day one after spine surgery with JP drains on.

Dr. Glen Stevens, DO, PhD:

Well, but just think about it. If you have lifts in the rooms, as you mentioned, yeah, the lift team will be there. The lift team's in six places. You're not there when they're there. Who knows when they're coming, six other things. But if you have that equipment right there, it makes it so much easier. And I remember when I used to round, I'd always say to the residents, "Check with the nurse. Is this person getting up? If they're not, why aren't they getting up?" And of course, the answer a lot of times was there was no lift team or it was not available or there was no devices on the ceiling that could help, and it just takes a lot. Everybody's busy and it was just difficult. I would suspect that pressure sores and all that type of stuff is less because people are getting up more. You already mentioned the rounds in the morning. Tell me about weekends.

Dr. Natalie Lilly, PT, DPT:

A lot of the patients that are getting seen in the ICU are new evals for us or new evaluations, and we work really hard to educate family members who their loved ones probably won't be seen over the weekend to advocate. When we do have really great nurses down there, if they are able, they will help these patients get to the chair, get out of bed with the ceiling lifts over the weekend. Or going back to that, the passive range of motion or exercises in bed, these are things that you can do with your loved one on Saturday and Sunday when we're not here.

Dr. Glen Stevens, DO, PhD:

But our goal is to get better. And as I mentioned in the 50s, we're so much better than that now. And sometime in the future, data will support that doing these things is so important that we should be bringing people in on Saturday and Sunday, even though people don't want to work Saturday and Sunday. There's always some that do, right? They've got children and work schedules with the other spouse. They want to work a Saturday, they want to work a. It seems like you wouldn't want to do that, but there are people that do want to do it. I think if we can provide the data of how important this is, and ultimately if it decreases length of stay, if it decreases complications, then we should do it.

Dr. Natalie Lilly, PT, DPT:

Sure.

Dr. Glen Stevens, DO, PhD:

So Adam, strokes, what's happened with rehabilitation in the stroke field? What have you seen in your career so far? Are we doing anything different than when you started day one or we're doing good stuff there and we're doing even better stuff now?

Dr. Adam Barron, MD:

I hope it was good stuff there. I think it's better stuff now. But the breadth of literature has evolved over time. A lot of literature in the general ICU population, but also in the neurological population focused early on on safety. Is it feasible to get these patients up? If we get them up, is it safe to ambulate them? When we're walking these patients through the ICU with devices and lines and tubes attached to them, is that a good idea? Are we causing harm? As the literature evolved, it essentially showed that in the breadth of the population, the answer is no, we're not causing harm, but is this helpful? And that's where the literature is moving is evaluating not just when, but how are we mobilizing and treating these patients. One thing that we do talk about a lot in the neuro ICU is that we know that when someone's brain is healing in the immediate hours after a stroke, that very, very early aggressive mobilization has not been shown to help and in fact can cause harm. So in the first 24 hours after a stroke, we do not aggressively mobilize people. We focus on the immediate stroke care that comes in an ICU or in step-down unit. But after that, we do know that early mobilization, not very, very early mobilization, but early mobilization is helpful. That has a big focus in therapy for these patients is early mobilization after their stroke is established after the first 24 hours.

Dr. Glen Stevens, DO, PhD:

Natalie, comments on that?

Dr. Natalie Lilly, PT, DPT:

No, I completely agree with what Dr. Barron is saying. The research, like you said, is showing anything before that 24-hour mark wasn't really beneficial for patients in their recovery and could also potentially cause harm. But after that 24-hour mark, as long as our patients are stable in the ICU, there were substantial benefits to starting mobilization at that time. I think there has even been some research coming out. Before it was kind of thought that at that time, short sessions throughout the day was better for these patients, but there is some research coming out that you can do some longer sessions with these patients. They can tolerate a little bit of a higher intensity and still get the same benefits out of that as well, which is great to see.

Dr. Adam Barron, MD:

A big focus on the inpatient side too is not just the actual early mobilization itself, but also the understanding of what lies ahead for these patients when they leave the hospital. Evaluation is also a big piece, understanding are these patients going to be best served by going to an inpatient rehab facility after this? Are they appropriate candidates for physical therapy in the home or in a physical therapy center? So that is also a key piece.

Dr. Glen Stevens, DO, PhD:

So are most of these people evaluated by a physiatrist?

Dr. Adam Barron, MD:

Sometimes physiatry comes in, but the first-

Dr. Glen Stevens, DO, PhD:

Or you don't need that?

Dr. Adam Barron, MD:

Well, they have a clear level of expertise, which is very helpful, especially in complicated patients who are at risk for medical complications that we don't always think about. I think a lot about our spinal cord injury population, for example, that's a specific type of population that has a lot of medical comorbidities and complications that physiatrists are really expert at dealing with, things like bladder and bowel changes that happen after your spinal cord is injured. They are a key piece of our ICU, but I would say that our therapy team is really kind of the first line of evaluation and understanding as to what these patients may need. We often get our physiatrists involved after the therapists have had the first few rounds of evaluation.

Dr. Glen Stevens, DO, PhD:

Do they have to see a physiatrist to go to rehab?

Dr. Adam Barron, MD:

Not always, but it can be important if it's necessary from an insurance standpoint. Physiatrists often carry an understanding as to the level of what patients are going to need immediately post-hospitalization, and they can be helpful in communicating that to insurance carriers that this is something that's necessary and good for the patients.

Dr. Glen Stevens, DO, PhD:

So a stroke's not a stroke's not a stroke. I mean, if you have an ischemic stroke, you have an intercerebral hemorrhage, you have a subarachnoid, maybe even a subdural epidural, I mean lots of different things. How do you treat these patients differently from a rehab standpoint?

Dr. Adam Barron, MD:

That's a great question. The first key is these patients need to be stable. We talked about how very, very early mobilization in the first 24 hours can be challenging, but the biggest thing is that these patients can have fluctuating courses depending on what they're presenting with. A large intracerebral hemorrhage may carry a slightly different course than someone who comes in with a smaller ischemic stroke. So priority number one is always medical stabilization and making sure that these patients are safe. After that, we know that across the neurological injury spectrum, whether it be traumatic brain injury, hemorrhagic stroke, ischemic stroke, subarachnoid hemorrhages, all of these patients benefit from therapy and early mobilization. You can imagine that this is a difficult thing to study. When you start looking into tiny pieces of patients' presentations, it can be challenging to get robust data to support all of that. But we know that in all comers, when we look at brain injury, these patients do benefit from early mobilization and therapy.

Dr. Glen Stevens, DO, PhD:

Natalie, I hope you don't spend a lot of your day going to a room up, getting a CT scan up, I'm doing a swallow study. I'm off the floor here. I'm off floor there.

Dr. Natalie Lilly, PT, DPT:

It definitely happens. We have days like that, but that's kind of why we like to round in the morning. A lot of the nurses, they kind of know what's on the agenda for their patients for the day and they can tell us they're going-

Dr. Glen Stevens, DO, PhD:

Map it out.

Dr. Natalie Lilly, PT, DPT:

Yeah, they're going for their swallow study at this time or this time. So that's kind of how we collaborate, but we're also very flexible. We have on that unit, at least on G20, there's 14 beds. So if bed one is off at a scan, I'm just going to go check someone else and I'll come back. And I think it's really nice that everybody is right there and usually when they're off at a test, we know if it's going to be a long time or a short time and kind of make our day around that.

Dr. Glen Stevens, DO, PhD:

So on a good day, I'm a little encephalopathic, so you come see me to do some therapy and I'm a little confused. How do you handle that or what do you do?

Dr. Natalie Lilly, PT, DPT:

So the one thing that I like to tell everybody is confused and not following commands doesn't mean that they can't do therapy.

Dr. Glen Stevens, DO, PhD:

I like that.

Dr. Natalie Lilly, PT, DPT:

Some people are-

Dr. Glen Stevens, DO, PhD:

Because it's easy to take the other road, isn't it?

Dr. Natalie Lilly, PT, DPT:

Exactly.

Dr. Adam Barron, MD:

It is. Yeah.

Dr. Glen Stevens, DO, PhD:

And that doesn't help anybody.

Dr. Adam Barron, MD:

No.

Dr. Natalie Lilly, PT, DPT:

You can hear not following commands and some people just kind of move on, but that's kind of our bread and butter in the ICU. And the best thing we can do is functional activity. So what kind of things would be more likely to be automatic for the patient? So for us, that's getting up, getting out of bed. For OT, it might be, can they use a toothbrush? Can they brush their hair? Can we go to the sink and do those sorts of things like washing our hands? And then for us, can they walk? If you're really weak, how can we promote walking? How can we promote weight-bearing and those types of activities that are more functional and more automatic for a patient that might be confused or not following commands as well.

Dr. Glen Stevens, DO, PhD:

Adam, any other thoughts on that?

Dr. Adam Barron, MD:

Yeah, I think a big focus. We think about this in the ICU a lot because we talk about extubation. So a patient with a breathing tube needs to have that breathing tube out at some point. If you're in a general ICU, one of the extubation criteria, one of the things they ask about is can the patient follow commands? There are a lot of patients in our ICU who cannot follow commands, and if we followed those rules, we wouldn't take the breathing tube. Everybody would have a breathing tube in forever. So we have to pivot a little bit and adapt to the patient population we have. Just because someone cannot follow commands or has aphasia, it does not mean that they're not going to benefit from rehab. In fact, those patients may benefit more from rehab, and so it's important to highlight that and do the best we can. That means we still have to do things like be safe, make sure that we have enough people to get these patients up safely, especially if we can't ask them to do things like sit down on their own, but it can still be done.

Dr. Glen Stevens, DO, PhD:

It's shocking, but our time is at the end. What have I not asked you that you think is important? Anything you want to highlight?

Dr. Natalie Lilly, PT, DPT:

We talked about early mobilization and not getting in too soon, but the earlier, the better when patients are stable and ready.

Dr. Adam Barron, MD:

One thing I'll highlight from the critical care side of things, we've talked a lot about the neurological rehabilitation of patients with strokes, but from a critical care aspect, one comment we get a lot is our loved one seems too sick to be able to mobilize. They have a breathing tube in, they have a big dialysis line and they've got IVs in both arms. How are we going to feasibly mobilize them? And one consistent thing that has been shown in the literature in both neurological patients and non-neurological patients is that with adequate support, this mobilization is safe and can help with things like DVTs, pressure injuries, ICU acquired weakness. And so, as long as we are taking the appropriate precautions, we have great educated therapists and nurses and team members who can help support this, it's a great early intervention to help minimize complications in our really sick patients.

Dr. Glen Stevens, DO, PhD:

And I'm sure these are the things you discuss at the morning rounds, right?

Dr. Natalie Lilly, PT, DPT:

We sure do.

Dr. Glen Stevens, DO, PhD:

And like everything else in medicine, it's just a matter of open discussion with families and patients about why we're doing things, why we're not, what we're trying to prevent. We can choose not to do it, but you're going to have to deal with this and it's only going to be worse, so let's do it. Well, listen, I appreciate you both joining me here today and appreciate all you do for our patients, and look forward to seeing you back on a future podcast.

Dr. Adam Barron, MD:

Thank you so much for having us.

Dr. Natalie Lilly, PT, DPT:

Thank you.

Closing:

This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's consultqd.clevelandclinic.org/neuro, or follow us on Twitter @CleClinicMD , all one word. And thank you for listening.