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Research Report

HOBOE (Head-of-Bed Optimization of Elevation) Study: Association of Higher Angle With Reduced Cerebral Blood Flow Velocity in Acute Ischemic Stroke
Abigail Jade Hunter, Suzanne J. Snodgrass, Debbie Quain, Mark W. Parsons, Christopher R. Levi
A.J. Hunter, BPhysio(Hons), St George Hospital, Sydney, New South Wales, Australia. S.J. Snodgrass, BSc(PhysTher), ATC, MMedSc(Physio), PhD, Discipline of Physiotherapy, School of Health Sciences, University of Newcastle, Hunter Building, Callaghan, New South Wales, 2308 Australia. Address all correspondence to Dr Snodgrass at: au. D. Quain, BSN, Hunter Stroke Service, John Hunter Hospital, Newcastle, New South Wales, Australia. M.W. Parsons, BMed, PhD, FRACP, Priority Research Centre for Brain and Mental Health, Hunter Medical Research Institute, University of Newcastle, Newcastle, New South Wales, Australia. C.R. Levi, BMedSc, MBBS, FRACP, RACP, Priority Research Centre for Brain and Mental Health, Hunter Medical Research Institute, University of Newcastle. [Hunter AJ, Snodgrass SJ, Quain D, et al. HOBOE (head-of-bed optimization of elevation) study: association of higher angle with reduced cerebral blood flow velocity in acute ischemic stroke. Phys Ther. 2011;91:1503–1512.] © 2011 American Physical Therapy Association Published Ahead of Print: August 25, 2011 Accepted: June 16, 2011 Submitted: August 18, 2010

Background. Cerebral autoregulation can be impaired after ischemic stroke, with potential adverse effects on cerebral blood flow during early rehabilitation. Objective. The objective of this study was to assess changes in cerebral blood
flow velocity with orthostatic variation at 24 hours after stroke.

Design. This investigation was an observational study comparing mean flow velocities (MFVs) at 30, 15, and 0 degrees of elevation of the head of the bed (HOB).

Methods. Eight participants underwent bilateral middle cerebral artery (MCA)
transcranial Doppler monitoring during orthostatic variation at 24 hours after ischemic stroke. Computed tomography angiography separated participants into recanalized (artery completely reopened) and incompletely recanalized groups. Friedman tests were used to determine MFVs at the various HOB angles. Mann-Whitney U tests were used to compare the change in MFV (from 30° to 0°) between groups and between hemispheres within groups.

Results. For stroke-affected MCAs in the incompletely recanalized group, MFVs
differed at the various HOB angles (30°: median MFV 51.5 cm/s, interquartile range [IQR] 33.0 to 103.8; 15°: median MFV 55.5 cm/s, IQR 34.0 to 117.5; 0°: median MFV 85.0 cm/s, IQR 58.8 to 127.0); there were no significant differences for other MCAs. For stroke-affected MCAs in the incompletely recanalized group, MFVs increased with a change in the HOB angle from 30 degrees to 0 degrees by a median of 26.0 cm/s (IQR 21.3 to 35.3); there were no significant changes in the recanalized group ( 3.5 cm/s, IQR 12.3 to 0.8). The changes in MFV with a change in the HOB angle from 30 degrees to 0 degrees differed between hemispheres in the incompletely recanalized group but not in the recanalized group.

Limitations. Generalizability was limited by sample size. Conclusions. The incompletely recanalized group showed changes in MFVs at various HOB angles, suggesting that cerebral blood flow in this group may be sensitive to orthostatic variation, whereas the recanalized group maintained stable blood flow velocities.

Post a Rapid Response to this article at: October 2011 Volume 91 Number 10 Physical Therapy f 1503

Establishing the impact of orthostatic changes for patients after ischemic stroke may contribute to more effective care and rehabilitation for patients with acute stroke. anterior circulation ischemia on computed tomography (CT) perfusion imaging.17–19 However. Method Participants Patients referred to a tertiary care hospital from April to August 2009 participated in this study. including sitting. Salvage of the penumbra is the focus of treatment for acute stroke. standing. and no direct measure of this mechanism is currently available. 24% of patients with acute ischemic stroke show spontaneous recanalization without receiving active revascularization treatment.14.9 Current physical therapy guidelines emphasize early rehabilitation after ischemic stroke. TCD studies of orthostatic blood flow changes in patients with stroke are limited.HOBOE Study: Bed Angle. Intravenous thrombolytic therapy has been reported to achieve arterial recanalization in 46% of appropriate patients. Obstructed blood flow. We hypothesized that patients whose arteries had not recanalized would display greater changes in blood flow velocities with orthostatic variations than patients whose arteries had recanalized and that the stroke-affected hemisphere would similarly experience greater changes in blood flow velocities than the nonaffected hemisphere.26 Patients enrolled in the study met the following criteria: 18 years of age or older. and the extent of any potential impairment in cerebral autoregulation is not clear. Blood Flow. One report9 described the use of TCD ultrasound to measure the impact of orthostatic changes on blood flow velocities in patients with acute ischemic stroke.21 Ischemic stroke typically is caused by occlusion of a cerebral blood vessel22 (commonly the middle cerebral artery [MCA]). results in the development of a necrotic infarct core surrounded by the ischemic penumbra. or walking. studies have not specifically investigated the physiological effects of orthostatic changes in patients showing early recanalization.23. This increase in blood flow velocity was accompanied by clinically observed neurological improvement. such as lying.10 –12 The clinical implications of changes in blood flow velocities in response to such orthostatic variations in the acute phase after ischemic stroke remain unclear. and walking. a National Institutes of Health Stroke Scale (NIHSS) score of 3 or greater.20.13–16 Transcranial Doppler ultrasound has been used in several studies investigating autoregulation. indicating an improvement in cerebral blood flow with the bed flat. The primary aim of this study was to describe changes in cerebral blood flow velocities in response to variations in orthostatic positions at 24 hours after ischemic stroke. a homeostatic mechanism that maintains adequate cerebral blood flow despite variations in systemic blood pressure and cerebral perfusion pressure. standing.24 Although thrombolytic therapy is considered the best practice for achieving arterial recanalization. Transcranial Doppler (TCD) ultrasound is a valid measure of blood flow velocity in the major cerebral arteries and is an accepted index of cerebral autoregulation. However. over time. The mechanisms contributing to cerebral autoregulation are complex.16. to facilitate optimal functional recovery.8 Orthostatic positions closer to vertical present a greater challenge to this mechanism.3. All patients had acute ischemic stroke with a duration of less than 6 hours since symptom onset and were considered for intravenous thrombolytic therapy. Secondary aims were to determine any differences in blood flow velocities with changes in positions between arteries that had recanalized and those that had not and between stroke-affected and nonaffected hemispheres. Cerebral blood flow velocity increased when the head of the bed (HOB) was lowered from 30 degrees to 0 degrees. it is unknown whether blood flow velocities respond differently to orthostatic changes in patients who show recanalization or whether there are differences between hemispheres. patients were excluded from the study if they showed recanalization. sitting. Thus. particularly when it is impaired after stroke. and a prestroke modified Rankin Scale score of 3 or less. in comparison. The delivery of intravenous thrombolytic drugs to dissolve clots and recanalize (reopen) blood vessels is now standard practice in the medical management of acute ischemic stroke. 1504 f Physical Therapy Volume 91 A an area of neural tissue with potentially reversible damage. The NIHSS is a nonlinear ordinal scale with scores from 0 to 42 that October 2011 Number 10 .1– 6 Cerebral autoregulation ensures sufficient blood flow with changes in body position that affect blood pressure.8.5.14. and Stroke cute ischemic stroke adversely affects cerebral autoregulation.7. To date. and measurements from the nonaffected MCA were not obtained.25 Patients whose stroke-affected arteries are recanalized often display rapid neurological improvement and often progress readily to rehabilitation and good recovery. Investigations of the physiological effects of orthostatic variation have used measures of cerebral blood flow velocity to indirectly reflect the maintenance of cerebral autoregulation. the sample size was determined by the number of eligible patients presenting within the 5-month data collection time frame.6. its success depends on early delivery and many individual patient factors.

or congestive cardiac failure.1. An acclimatization period of 5 minutes with continuous TCD observation ensured the stability of blood flow velocities in the participants. such as sitting and standing. Seattle. The area of insonation then was positioned in the mid-M1 MCA segment in participants with complete recanalization and at the point just proximal to the site of occlusion where blood flow was detected in participants with incomplete recanalization. The participant’s hip joints were aligned with the hinge of the bed to ensure consistency of body position when the HOB was lowered and raised. A score of 3 or less indicates no significant preexisting disability. autoregulation typically responds rapidly to positional changes in people who are healthy. Procedure. Figure 1 shows the progression of participants through the study. Spencer Technologies. the score was obtained from family interview upon a patient’s presentation to the hospital. The head frame was fitted and all measurements were obtained by the same experienced neurosonographer to maintain consistency throughout the procedure. Computed tomography or magnetic resonance angiography at 24 hours after stroke was used to determine arterial recanalization status and group participants accordingly. Blood flow velocities were measured by TCD ultrasound examination with a digital powermotion Doppler unit (PMD 100. and 30 degrees. A 10-mm area of insonation enabled optimal waveform visualization. Next. positioned over the temporal bone windows.32 A specialist nurse qualified in administering the NIHSS determined a baseline NIHSS score during the initial neurological examination and repeated the test after 24 hours. Queensland.28 A score of 3 or greater indicates a stroke of sufficient severity to be considered for thrombolytic therapy. and angled to detect the optimal MCA signal. secondary to chronic obstructive pulmonary disease. measured by TCD ultrasound. asthma. Albany Creek. In addition. the HOB was lowered to 15 degrees. for example. New Hampshire) and calibrated against the horizontal position by one researcher before testing for each participant. Written informed consent was obtained from all patients’ families before recruitment into the study. if temporal bone windows were insufficient to enable ultrasound penetration.26. this step was followed by a 5-minute acclimatization period and then 1 minute of data recording. who were expected to have impaired autoregulation because of stroke. 15. Patients unable to tolerate the TCD ultrasound procedure because of agitation were also excluded. Blood Flow. A rapid-response stroke team (a neurologist and a specialist nurse) examined the participants and completed a thorough neurological assessment. or if they had substantial comorbidities that were life threatening or that limited their ability to lie flat in bed. Washington) and 2-MHz pulsed-wave diagnostic transducers at depths of 40 to 65 mm. Thrombolytic therapy was administered subsequent to specific criteria being met. The modified Rankin Scale provides a measure of functional disability and physical dependence29.31).27. monitoring the stabilization of cerebral blood flow in these positions was important. Equipment. and Stroke provides a valid and reliable assessment of acute stroke-related deficits. The TCD ultrasound protocol was initiated at an HOB elevation angle of 30 degrees because the participants routinely rested in this position. The dependent variable was MCA blood flow velocity. hence. Plain head CT was used to exclude hemorrhagic stroke and was followed by CT perfusion imaging and angiography to determine the extent of ischemia and the site of occlusion. Incomplete recanalization was defined as partial or complete MCA occlusion and incomplete restoration of blood flow velocity. Computed tomography or magnetic resonance angiography at 24 hours after stroke was used to determine recanalization status and group participants accordingly. Complete recanalization was defined as full reopening of the affected artery and restoration of normal blood flow velocity (mean flow velocity [MFV] in a normal MCA is approximately 55 cm/s [SD 12]30. The manipulated independent variable was the angle of HOB elevation: 0. Blood flow velocities were measured at 5-mm increments along the MCA to detect the site of occlusion. Australia). The Plurimeter was attached to the bed frame with Velcro (Velcro USA Inc. The angle of HOB elevation was standardized with a Plurimeter (Australasian Medical & Therapeutic Instruments. This proNumber 10 Physical Therapy f 1505 Volume 91 .21 Early rehabilitation includes prolonged periods of upright positions. Patients were excluded from participation if CT imaging revealed posterior circulation or hemorrhagic stroke. The acclimatization period was followed by 1 minute of data recording.HOBOE Study: Bed Angle. a liquid pendulum inclinometer. Bilateral transducers were attached to the participant with a Marc 600 head frame (Spencer Technologies). Manchester. The TCD ultrasound protocol then was used to investigate MCA blood flow velocities at various HOB elevations. October 2011 Study Design and Protocol This observational study followed a repeated-measures design. patients were excluded if they displayed symptomatic orthopnea at the time of TCD data collection.

HOB head of bed elevation. CT computed tomography. TCD transcranial Doppler ultrasound. NIHSS National Institutes of Health Stroke Scale. Blood Flow.HOBOE Study: Bed Angle. MCA middle cerebral artery. MR magnetic resonance. Flow diagram showing the progression of participants through the study.26 1506 f Physical Therapy Volume 91 Number 10 October 2011 . *Eligibility for thrombolytic therapy was described by Quain et al. and Stroke Consecutive patients with stroke=35 Excluded=27 Reasons for exclusion: No MCA territory on CT imaging=7 Insufficient temporal bone windows for TCD=5 Unable to tolerate position changes due to: • orthopnea=4 • agitation=2 • critically unwell=2 Unable to complete TCD protocol due to: • death or discharge from hospital=3 • CT angiography not performed=1 • neurosonographer unable to attend=2 • patient declining participation=1 Enrolled in study=8 Inclusion criteria: CT: MCA circulation ischemia NIHSS score ≥3 Modified Rankin Scale score ≤3 Written consent from family member Thrombolytic therapy commenced for appropriate patients=5 Thrombolytic therapy not commenced=3 Patients did not meet standard criteria to qualify for thrombolytic therapy* 24 hours MR angiography Recanalized=4 Incompletely recanalized=4 TCD protocol 30º HOB 15º HOB 0º HOB Figure 1.

15°: median MFV 55. IQR 34. To ensure participant safety. Spacelabs Healthcare. Chicago.021). Issaquah. and CT images to ensure unbiased and accurate interpretation of waveforms. whereas in the recanalized group. there was a median increase in the MFV (from that at 30° of HOB elevation to that at 0° of HOB elevation) of 26.26 Angiography at 24 hours after stroke determined that 4 participants showed complete recanalization of the affected artery (recanalized group) and that 4 participants showed partial recanalization (incompletely recanalized group).8) (P value for between-group difference for MFV change . Statistical analyses were performed with PASW Statistics 18.35 To further monitor participant safety. and Stroke cess was repeated at an angle of HOB elevation of 0 degrees (bed flat). diagnosis. The strokeaffected MCA in the incompletely recanalized group was the only artery to demonstrate a significant difference in MFVs at various HOB angles (30°: median MFV 51.5 cm/s. and the MFVs from each assessor were averaged to obtain a single value that was used in further analysis.039). Outcome Measures Transcranial Doppler ultrasound produced a 1-minute recording of flow velocity waveforms. There were no significant differences for nonaffected MCAs. and Wilcoxon signed rank tests were used to determine differences between pairs of HOB angles. Blood Flow Velocities The MFVs for individual participants are shown in Table 2. complications of increased intracranial pressure were not expected within the first 24 hours because increased intracranial pressure usually peaks at 48 hours after ischemic stroke or later.0 (SPSS Inc.5 cm/s. Data Analysis Analysis of TCD waveforms was performed by reviewing the continuous TCD data files (Fig. Five participants (4 women and 1 man) received thrombolytic therapy after being selected as eligible for this therapy according to current clinical guidelines. or between pairs of HOB angles for any group or hemisphere. The safety of the participants was ensured by beginning the protocol at the normal resting HOB elevation (30°) and progressively lowering the bed to the horizontal position. IQR 58.34. interquartile range [IQR] 47. and the values were then averaged over the 1-minute recording period after acclimatization at each HOB angle. 2). Washington) were concurrently measured during data collection to identify any physiological changes with manipulation of the HOB angle. 0°: median MFV 85.5 years) were enrolled in the Volume 91 . MannWhitney U tests were used to compare changes in MFVs (from those at 30° to those at 0°) between groups and between affected and nonaffected sides within groups. for the strokeaffected MCA in the recanalized group. The MFV was calculated for each waveform over the 1-minute recording period. mean arterial pressure. Illinois). heart October 2011 rate. No participants showed persistent complete occlusion at 24 hours. The MFV was determined for each waveform.8. Blood flow velocity was expected to be greater in the horizontal position than at higher angles of HOB elevation in participants in the acute phase after ischemic stroke9. IQR 12. Figure 3 shows the observed change in the MFV (from that at 30° of HOB elevation to that at 0° of HOB elevation) for the stroke-affected MCA in the incompletely recanalized group.0 cm/s. model 90369. a pulsatility index (a TCD measure of resistance to flow) was monitored throughout the procedure. 1). the horizontal position potentially posed less risk of ischemic damage than the participants’ normal resting position. there was no observable change (median difference 3. 8 patients (5 women and 3 men. This protocol provided 1 minute of continuous data for analysis per HOB angle per participant. A high pulsatility index reflects elevated resistance to flow and may be indicative of increased intracranial pressure. The MFVs in the nonaffected MCAs in both groups also did not change significantly Number 10 Physical Therapy f 1507 Results Of 35 patients who were screened for inclusion.0 to 103.33 However.0 to 117. therefore. Role of the Funding Source No funding was required for this research. Friedman tests were used to compare MFVs at the 3 HOB angles for affected and nonaffected MCAs in the incompletely recanalized and recanalized groups.3). and there are no financial conflicts of interest.5. For the stroke-affected MCA in the incompletely recanalized group. The change in MFV (from 30° to 0°) was used to compare differences between affected and nonaffected MCAs both within and between the recanalized and incompletely recanalized groups. study (Fig. The MCA MFV was the primary outcome measure used to compare differences between HOB angles. The files were assessed at a time and a location separate from those for participant data collection by an experienced neurosonographer and a neurologist.20.3 to 0.3 to 35.8 to 127. Both assessors were unaware of participants’ identification. Participant demographics and NIHSS scores are shown in Table 1. Blood Flow.0 to 74.0) (P . IQR 33.0 cm/s (IQR 21. and blood oxygen saturation (Spacelabs Healthcare telemetry.HOBOE Study: Bed Angle. median age 66 years.5 cm/s.

HOBOE Study: Bed Angle. Blood Flow. Sample blood flow velocities in affected and nonaffected middle cerebral arteries (MCAs) at 30 and 0 degrees of elevation of the head of the bed (HOB) in a participant in the recanalized group and a participant in the incompletely recanalized group. flow remained relatively unchanged. and Stroke Figure 2. 1508 f Physical Therapy Volume 91 Number 10 October 2011 . Blood flow velocity in the affected MCA in the participant in the incompletely recanalized group was greater at 0 degrees than at 30 degrees. whereas in the nonaffected MCA.

and 95. The difference between affected and nonaffected hemispheres in the change in MFV (from 30° of HOB elevation to 0°) was significant for the incompletely recanalized group (P .309).5 mm Hg (IQR 87. Blood Flow.8) (P value for between-group difference for median MFV change .0.HOBOE Study: Bed Angle. Average Valuesa for Stroke-Affected and Nonaffected Middle Cerebral Arteries by Angle of Elevation of the Head of the Bed (HOB) and Recanalization Status at 24 Hours After Stroke Mean Flow Velocity (cm/s) in Participants Showing: Stroke Status of Middle Cerebral Artery Affected by stroke Not affected 15° HOB elevation Affected by stroke Not affected 0° HOB elevation Affected by stroke Not affected Change from 30° to 0° HOB elevation % change from 30° to 0° HOB elevation a Incomplete Recanalization at 24 h 1 67 76 77 70 97 66 30 10 45 13 2 116 91 131 88 137 89 21 2 18 2 3 32 54 34 51 54 60 22 6 69 11 4 36 45 34 42 73 38 37 6 104 14 Complete Recanalization at 24 h 5 50 46 46 49 43 48 7 2 14 4 6 32 43 34 45 33 44 1 1 3 2 7 30 34 30 29 30 30 0 4 0 12 8 45 35 31 29 31 32 14 4 32 10 Parameter 30° HOB elevation Affected by stroke Not affected Affected by stroke Not affected Over a 1-minute acquisition period.5).5) at HOB angles of 30. Participant Demographics at Baseline and 24-Hour Follow-upa Participant 1 2 3 4 5 6 7 8 a Age (y) 31 49 78 68 45 64 74 75 Sex F F F F M M F M Recanalized at 24 h No No No No Yes Yes Yes Yes Thrombolytic Therapy Yes Yes Yes Yes No No No Yes Affected Middle Cerebral Artery Right Right Left Right Left Left Left Left Baseline NIHSS Score 15 12 11 17 4 10 3 13 24-h NIHSS Score 17 13 3 12 1 9 2 1 Change in NIHSS Score 2 1 8 5 3 1 1 12 Baseline at presentation to hospital within 6 hours of symptom onset. Table 2.5 mm Hg (IQR 90. and Stroke Table 1.5 mm Hg (IQR 90 to 108.9 to 1. Discussion The main finding of the present study was that MFVs in strokeaffected MCAs with incomplete recanalization increased as the HOB was lowered from 30 degrees to 0 degrees.0 to 4. Median mean arterial pressures (all participants) were 98. no clinically significant changes in heart rate or blood oxygen saturation were observed.5 to 105). The lower October 2011 Volume 91 Number 10 Physical Therapy f 1509 . 97. NIHSS National Institutes of Health Stroke Scale.5 to 103. IQR 3. IQR 9. No statistically significant changes were observed in nonaffected MCAs or MCAs with complete recanalization. median difference in the recanalized group 1.020) but not for the recanalized group (P . In addition. respectively. 15. and 0 degrees.0 cm/s. The lack of a significant orthostatic variation in blood flow velocity after CT angiographic evidence of recanalization suggests intact autoregulation in the territory of the affected MCA.564). There were no marked differences in the pulsatility index at the 3 HOB angles. Safety No adverse events occurred during testing. (median difference in MFV between 30° and 0° of HOB elevation in the incompletely recanalized group 4.3.

This result suggests that the vasodilatory responses necessary to maintain constant cerebral blood flow in body positions approximating horizontal were impaired in these participants. because continued improvements in the efficacy of thrombolytic therapy are likely to increase rates of arterial recanalization. Interestingly. and Stroke sons with the present study. Schwarz et al21 used bilateral TCD ultrasound measurements and identified a significant difference in blood flow velocities between affected and nonaffected hemispheres but no significant change in the nonaffected MCA. Two reports9.” The implications for rehabilitation are that the early use of upright postures may place greater orthostatic stress on circulating blood volumes in participants who show evidence of incomplete recanalization.21 documented the investigation of TCD ultrasound–measured MFVs with variations in the angle of the HOB of 0 to 30 degrees. in the present study. in this situation. Schwarz et al21 did not categorize patients according to arterial recanalization. One of these studies. This factor limits the generalizability of their findings. whereas hyperperfusion in the first 48 hours October 2011 Figure 3. However.9 excluded patients who showed recanalization. The clinical impact of MFVs that are greater than normative values is uncertain. In the other study. 3 of the 4 participants who showed complete arterial recanalization did not receive thrombolytic therapy. Increased MFVs beyond 48 hours after stroke onset are associated with hyperperfusion injury and hemorrhagic transformation. particularly with regard to future populations. Interestingly. a factor that limits comparisons with the present study. our small sample suggests that they may not be inconsistent with documented outcomes for this therapy in the literature.21 suggesting that cerebral perfusion may be impaired predominantly in the stroke-affected hemisphere. Box plots illustrating differences between affected and nonaffected middle cerebral arteries (MCAs) by group (recanalized or incompletely recanalized) in changes in mean blood flow velocities when the head of the bed was lowered from 30 degrees to 0 degrees at 24 hours after ischemic stroke. suggesting greater stability of blood flow in these participants. in our sample. Both studies identified a greater MFV in the stroke-affected MCA at 0 degrees of HOB elevation than at 30 degrees of HOB elevation. although important differences in patient selection and study design limit compari- Number 10 . whereas all participants in the incompletely recanalized group retained partial arterial occlusion despite the administration of thrombolytic therapy. blood flow velocity with HOB elevation in participants who did not show CT angiographic evidence of recanalization raises the possibility that. Blood Flow. we identified large increases in MFVs in participants with incompletely recanalized arteries when the HOB was lowered to horizontal.25 The lack of recanalization in participants receiving thrombolytic therapy in the present study probably reflects individual responses to treatment in our small sample and does not represent a limitation to the external validity of the present study. Comparisons With Previous Research Few studies have investigated the effects of changing orthostatic positions on cerebral blood flow velocities in acute ischemic stroke. we identified no significant changes in MFVs with orthostatic variations in either hemisphere in participants who showed complete recanalization. by WojnerAlexandrov et al. The findings for the incompletely recanalized group in the present study agree with the results of Schwarz et al. the affected MCA territory may have had a decreased capacity to autoregulate and adapt to orthostatic “stress. Physiological Rationale In the present study. Although these results are contrary to expec1510 f Physical Therapy Volume 91 tations for thrombolytic therapy. The findings suggest that implementing a routine CT examination at 24 hours after stroke may improve clinical decision making during early rehabilitation.HOBOE Study: Bed Angle.

However.36 Furthermore.HOBOE Study: Bed Angle. blood flow velocities were sensitive to orthostatic changes.10. However. displayed significant changes in blood flow velocities with manipulation of the HOB between 0 and 30 degrees. standing. including sitting. TCD ultrasound may introduce some error because the measurements are operator dependent. 2) displayed significantly greater MFVs in the stroke-affected hemisphere than did the other participants. participants who showed recanalization early after stroke maintained greater stability of blood flow velocities during orthostatic changes at low angles of HOB elevation than participants who showed incomplete recanalization. Limitations The sample size in the present study was small and limited the power of statistical calculations. The implications of increased MFVs are uncertain. 6. a result that may have been representative of a normalization of cerebral autoregulation. when the HOB was lowered to horizontal. Participants who showed recanalization may have retained blood flow stability in orthostatic positions closer to vertical. In the present study. the association between body positions and MFVs in the acute phase after ischemic stroke in patients whose arteries remain occluded supports the biological rationale that orthostatic positions closer to vertical may present a potential risk of cerebral hypoperfusion. and walking. One report37 documented that a decrease in blood flow velocity of greater than 70% during carotid clamping for endarterectomy was predictive of adverse clinical events. TCD ultrasound is widely accepted as a safe and reliable noninvasive technique for measuring cerebral blood flow velocity. blood flow velocities in affected MCAs that had not completely recanalized increased. Conversely.21 In contrast.39 identified decrements of 85% occurring without clinical consequences. these participants may have been more vulnerable to cerebral hypoperfusion in orthostatic positions closer to vertical. patients in the acute stroke unit where the present study was conducted begin rehabilitation. However. Participants who showed complete recanalization appeared to demonstrate greater stability of blood flow velocities. increased MFVs with the bed in the flat position were previously associated with clinically significant neurological improvement in 3 of 20 patients who did not show recanalization. Participants who did not show complete recanalization. 4 or 5 days after stroke. the impact of rehabilitation on blood flow velocities during this acute phase is uncertain. in participants whose recanalization was incomplete. however. commencing within 24 hours after stroke. the apparent impact that arterial recanalization has on blood flow responses to orthostatic changes suggests a potential for imaging services to play a greater role in informing clinical decisions pertinent to rehabilitation in the future. even at low angles of HOB elevation. but it was necessary to ensure the safety of the participants. the inclusion of participant 2 in the present study means that the conclusions should be interpreted with caution. although other studies38. PreviVolume 91 ous studies indicated the association of positive neurological outcomes with increased MFVs with the bed in the flat position. Consistency and accuracy in the present study were ensured by the use of one experienced neurosonographer. potentially detrimental effects of increased MFVs in patients with impaired cerebral autoregulation cannot be excluded.9 Previous studies suggested that adopting a resting position of 0 degrees of HOB elevation may be beneficial for patients who do not show recanalization. Therefore.11 However. This factor may limit the generalizability of the findings. Follow-up angiography to determine arterial recanalization after stroke is not currently part of routine clinical practice. and Stroke appears to be associated with neurological improvement without increased risk of hemorrhage. Typically. Furthermore. 1 participant in the incompletely recanalized group (participant 2. Additionally. Conclusion and Future Directions In the present study. Thus. the most appropriate point at which to begin rehabilitation is not specified. Another limitation of the present study was the exclusion of patients who were unable to tolerate horizontal positioning because of symptomatic orthopnea. Tab. However.9 However. Other authors12 investigated the effects of very early rehabilitation. Future studies with larger sample sizes are indicated to validate the findings of the present study as well as to examNumber 10 Physical Therapy f 1511 . there were no statistically significant changes in arteries that had completely recanalized. The clinical impact of large decreases in blood flow velocity in patients with acute stroke is unknown.9 as long as the intracranial pressure remains stable. and 12 months of follow-up in groups receiving either very early rehabilitation (getting patients out of bed within the first 24 hours) or standard care. the effect on cerebral blood flow of raising the HOB above 30 degrees has not yet been studied. Blood Flow. Phase II of the AVERT (Very Early October 2011 Rehabilitation Trial for Stroke) study40 identified similar numbers of deaths and levels of disability at 3. Implications for Rehabilitation Physical therapy guidelines currently advocate early rehabilitation after ischemic stroke to facilitate the optimal recovery of physical function.

Cavrini G. 8 Novak V. Using the NIH Stroke Scale to assess stroke patients: the NINDS rt-PA Stroke Study Group. J Neurol. 38 Anzola GP. 30 Kasaab MY. deterioration. et al. Novak P. et al. et al.6:63– 69. Farooq MU. Dr Parsons provided project management and institutional liaisons. et al. 2008.25:793–797. van den Berg JC.29:2038 –2042.95:1439 –1445. et al. Fernandez Cisneros L. Int J Stroke. Neurology.40:2507–2511. et al. 24 von Kummer R. et al. Transcranial Doppler sonography pulsatility index (PI) reflects intracranial pressure (ICP). et al. Changing cerebral blood flow velocity by transcranial Doppler during head up tilt in patients with diabetes mellitus. 2006. 2008. et al. 15 Newell DW. Predictors of carotid clamping intolerance during endarterectomy that would be wise to apply to stenting procedures. Newell DW. Nornes H. Black SE. 2005.19:467– 482. Lancet.45:1286 –1290. Lev MH. 21 Schwarz S.64:1354 –1357. 2001.165:311–317. Transcranial Doppler monitoring during head upright tilt table testing in patients with suspected neurocardiogenic syncope. Early postischemic hyperperfusion: pathophysiologic insights from positron emission tomography. 2011. 39 Doblar DD. et al. Plyushcheva NV. 2004. Comparison of static and dynamic cerebral autoregulation measurements. Stroke.33:497–501.7:547–554. 34 Hacke W. 18 Blissitt PA. et al. Management of adult stroke rehabilitation care: a clinical practice guideline.07). Prediction of early cerebral outcome by transcranial Doppler monitoring in carotid bifurcation angioplasty and stenting. Alberts MJ. Clinical Guidelines for Stroke Rehabilitation and Recovery. 2008. Assessment of cerebral autoregulation dynamics from simultaneous arterial and venous transcranial Doppler recordings in humans.38:1091–1096. Lam A. 1995.20100271 10 National Stroke Foundation (Australia).189:429 – 433. Outcomes validity and reliability of the modified Rankin scale: implications for stroke clinical trials—a literature review and synthesis. Blood Flow. Alexandrov AV. Pellegrini GL.1:169 –171. Predicting the effect of carotid artery occlusion during carotid endarterectomy: comparing transcranial Doppler measurements and cerebral angiography. Heads down: flat positioning improves blood flow velocity in acute ischemic stroke. Dr Parsons and Dr Levi provided participants and facilities/equipment. Laino R. Cerebral autoregulation dynamics in acute ischemic stroke after rtPA thrombolysis. All authors provided concept/idea/research design and consultation (including review of manuscript before submission). Loudfoot A. Dr Snodgrass. Recommendations for imaging of acute ischemic stroke: a scientific statement from the American Heart Association. 16 Reinhard M.29: 104 –111. Dewey H. Hachinski VC.46:393–397. et al. Ms Quain and Dr Parsons provided data collection. Saver J. Junger E. Wihler C. Georgiadis D. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS. 31 Vavilala MS. Autoregulation of cerebral blood flow in orthostatic hypotension. 1994. 2009. Lam AM. Dewey H. CMAJ. 6 Tiecks FP.15:492– 496. Stroke. Aaslid R. Uzunca I. September 14. 1995. Dynamic cerebral autoregulation is preserved during acute head-down tilt. Olsen KS. Strandgaard S. Mitchell PH. 9 Wojner-Alexandrov AW. and Stroke ine the physiological effects and clinical implications of orthostatic positions closer to vertical in the acute phase after ischemic stroke. 11 Duncan PW. 1989. Norris JW. South Australia. 26 Quain D. 1997. Spies JM. 32 Hacke W. et al.41:618 – 624. 25 Rha J. Aschoff A. Stooss R. Garami Z. Interplay of cerebral autoregulation and neurovascular coupling evaluated by functional TCD in different orthostatic conditions. J Vasc Surg. 2005. Stroke. 33 Bellner J. Donnan G. Cerebral autoregulation. Branston NM. Cerebrovasc Dis. Aaslid R. Roth M. An abstract presentation of this study was given at Stroke 2011: the 22nd Annual Scientific Meeting of the Stroke Society of Australasia. Stroke. Europace. Majid A. Ms Hunter. Lewis AJ. Australia. 2005. Lindegaard KF. Chernyshev OY. Kongable G. Stroke.2:161–192. Thrift A. 27 Lyden P. Improving access to acute stroke therapies: a controlled trial of organised prehospital and emergency care. Barch C. Stroke.53:309 –315. Bates B. 2007. Limoni P. 7th ed. et al. Cerebrovasc Brain Metab Rev. 20 Frank JI. et al. Strong AJ. 12 Bernhardt J. et al. 35 Silver FL.26:147–155. Young AR. and NINDS rt-PA stroke trials. et al. 2002. New South Wales. Ms Hunter and Dr Snodgrass provided writing. 13 Larsen FS. Update on intravenous tissue plasminogen activator for acute stroke: from clinical trials to clinical practice.62:45–51. Jordan W. Holle R.254:236 –241. 1512 f Physical Therapy Volume 91 Number 10 October 2011 . Balci K. Zorowitz R. 4 Paulson OB. Am J Crit Care. Stroke. 2007. J Neurosci Nurs. Arch Neurol. Newell DW. Transcranial Doppler is valid for determination of the lower limit of cerebral blood flow autoregulation. Transcranial Doppler: an introduction for primary care physicians. and intracranial pressure. Stroke. Rosengarten B.39:390 –396. 1996. DOI: 10. ‘Malignant’ middle cerebral artery territory infarction: clinical course and prognostic signs. 2005.26:581–587. et al. Autoregulation in acute focal ischemia: an experimental study. Pathophysiology: Concepts of Altered Health States. Med J Aust. 2005.20:45–52. Surg Neurol. Adelaide. 7 Azevedo E. 2004. 1995. Cerebrovascular dynamics with head-ofbed elevation in patients with mild or moderate vasospasm after aneurysmal subarachnoid hemorrhage. Sorteberg W. 1984. Utku U. Raman R. Stroke. The impact of recanalization on ischemic stroke outcome: a meta-analysis. and Dr Parsons provided data analysis.22:1148 –1154. 2007. 25:1985–1988. Stroke. 14 Latchaw RE. 1990. J Cereb Blood Flow Metab. 1998. Stroke. Early mortality following stroke: a prospective review. J Appl Physiol. Effects of body position on intracranial pressure and cerebral perfusion in patients with large hemispheric stroke. 5 Symon L.36:e100 – e143. Comparison of flow and velocity during dynamic autoregulation testing in humans. McDowell H. Canberra. 28 Spilker J. 1999. 2 Aaslid R.2522/ptj. 2007. Schwab S. 23 Gladstone DJ. Newell DW. 1998. Marotta CA. et al.38:967–973. Rosin L. Acta Anaesthesiol Scand. Reinstrup P. 2006. A very early rehabilitation trial (AVERT). Fieschi C. A very early rehabilitation trial for stroke (AVERT): phase II safety and feasibility.26:1014 –1019. 2004. Does arterial recanalization improve outcome in carotid territory stroke? Stroke. Hansen BA. Collier J. Newell DW. Stroke. Dynamic cerebral autoregulation in healthy adolescents. 29 Banks JL. 40 Bernhardt J. Cerebrovasc Dis. Philadelphia. et al. 2009. et al. Schwab S. Australia: National Health and Medical Research Council. Parsons M. 2007. ECASS. Edvinsson L.HOBOE Study: Bed Angle. Stroke. Cerebral autoregulation dynamics in humans. References 1 Aaslid R. Liu L. Horn M. 2003. Santos R. National Institutes of Health Stroke Scale certification is reliable across multiple venues. 3 Asil T. Baron JC. 2002. 17 Albina G. Approval for this study was granted by the Hunter New England Area Health Service Human Research Ethics Committee (ref: 03/09/10/3. Stroke.26:494 –501.40:3646 –3678. Suttorp MJ. 1976. Romner B. 36 Marchal G.363:768 –774. Large hemispheric infarction. 19 Cooke WH. 37 Ackerstaff RG. 1994. Stroke. 1991. Kovalenko OA.20:65–71.109:1– 6. Low PA. 22 Porth CM. Clin Neurol Neurosurg. PA: Lippincott Williams & Wilkins. Neurology. 2008.15:206 –216.29:384 –392. J Am Board Fam Med. Stroke.

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