Early mobilisation after thrombolysis in acute stroke
Mrs Wong, 74, was admitted 18 hours ago with right hemiparesis and aphasia due to a left middle cerebral artery infarct. She received intravenous alteplase 14 hours ago. Her NIHSS is 11. Blood pressure is now 176/94 mmHg, having been 190/100 mmHg earlier. Heart rate is 88/min, SpO2 97% on room air, temperature 36.8°C, and blood glucose 7.8 mmol/L. She is drowsy but awake, follows one-step commands inconsistently, and has dense right arm weakness (MRC grade 1/5) and right leg weakness (MRC grade 3/5) with poor trunk control. She has a nasogastric tube and an indwelling urinary catheter. The physiotherapy referral says 'mobilise as soon as possible'. The nurse asks whether she can sit out in the chair.
1. Is she safe to mobilise now? Apply relevant criteria and explain your reasoning.
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She is not ready for routine out-of-bed mobilisation, although she is not necessarily unsafe for careful positioning and sitting. Key issues are: she is only 14 hours post-alteplase, many stroke protocols avoid vigorous mobilisation within the first 24 hours because of the risk of haemorrhagic transformation and blood pressure instability; her blood pressure is 176/94 mmHg, which is below the usual 180/105 mmHg threshold for thrombolysis but still high and labile; she is drowsy with inconsistent command following; and she has a nasogastric tube and catheter, which increase handling and dislodgement risks. Her NIHSS is moderate, and trunk control is poor.
I would not start standing or walking. I would check the stroke unit protocol and the medical team's instructions. If she is neurologically stable, sitting on the edge of the bed with a hoist and two staff may be reasonable for a short period, provided blood pressure is monitored before and after. If there is any deterioration in consciousness, new headache, vomiting, or rising blood pressure, I would defer and escalate. The decision is a risk-benefit judgement, not a blanket rule.
2. What assessment and positioning would you do now, and what would you defer?
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Now I would assess conscious level, command following, pupil response if indicated, blood pressure, heart rate, oxygen saturation, pain, and the security of the nasogastric tube and catheter. I would screen for swallowing safety only in liaison with nursing and speech therapy, because of the nasogastric tube. I would assess passive range of movement, tone, sensation, and skin integrity, and check for shoulder subluxation. I would assess sitting balance only with full support and a hoist, not by pulling on her weak arm.
I would position her in bed with the head of the bed elevated to 30 degrees, the right arm supported on a pillow to prevent shoulder pain and subluxation, and the hips and knees in neutral. I would defer standing, gait practice, and transfers that require weight bearing until she is more alert and at least 24 hours post-thrombolysis with stable neurology. I would defer any vigorous range of movement or stretching of the weak arm. I would document the reason for deferral and communicate it to the nursing team.
3. Outline a safe early mobilisation progression and monitoring plan for the next 48 hours.
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Over the next 24 hours, continue positioning and passive or active-assisted range of movement for the right arm and leg, with shoulder support. If she remains stable, attempt sitting on the edge of the bed with a hoist and two staff for 5–10 minutes, monitoring blood pressure before, during, and after. If systolic blood pressure falls by more than 20 mmHg or she becomes drowsy, stop. After 24 hours post-thrombolysis, if the medical team agrees and her blood pressure is below 180/105 mmHg, progress to sitting in a chair with full support for 15–20 minutes, then standing with a standing hoist or tilt table if she can bear weight.
Monitor neurological status, blood pressure, heart rate, oxygen saturation, and fatigue. Stop for new weakness, headache, vomiting, reduced consciousness, chest pain, or desaturation. Involve nursing, speech therapy, and occupational therapy. Document each session and the reasons for any limitation. The plan should be individualised, gradual, and reviewed daily, with the aim of preventing complications such as deconditioning, pressure injury, and aspiration while avoiding harm.