Biologic Mechanisms of Early Exercise After Intracerebral Hemorrhage: a Pilot Randomized Controlled Trial of Cycle Ergometry
Phase: NA
Conditions: Intracerebral Hemorrhage, Acute Ischemic Stroke
Sponsor: Johns Hopkins University

Biologic Mechanisms of Early Exercise After 
Intracerebral Hemorrhage
NCT04027049
7/10/2020

 
 
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Date: _July 10, 2020___________________    
Principal Investigator: Elizabeth Zink_________________ 
Application Number: IRB00154440___________ 
 
 
 
JHM IRB - eForm A – Protocol 
 
 
 
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1. 
Abstract 
a. Provide no more than a one page research abstract briefly stating the problem, the research 
hypothesis, and the importance of the research. 
 
While recent advances in the treatment of acute ischemic stroke (AIS) have dramatically improved 
functional recovery for many patients, the burden of disability from ischemic stroke remains and more than 
half of patients with spontaneous intracerebral hemorrhage (sICH) remain disabled at one year post-
stroke.4,14,36-37 There is an urgent need to develop interventions aimed at reducing the burden of severe 
disability in patients with ischemic and hemorrhagic stroke. 
The innate immune response is triggered by an ischemic or hemorrhagic insult initiating a cascade 
of biochemical processes activating white blood cells, macrophages and microglia.3,15,17,29-30 The expression 
of the pro-inflammatory M1 cytokine phenotype predominates in the early period after AIS and sICH and 
is thought to worsen secondary brain injury. The anti-inflammatory M2 phenotype, including brain derived 
neurotrophic factor, demonstrates a slower ascent to peak and is associated with tissue repair.9,18,55 
Intervening to effect a balancing of M1 and M2 cytokines and accelerated expression of BDNF may 
increase the capacity for tissue repair. 
Animal and human studies have demonstrated that moderate intensity exercise when compared to 
exertional exercise or strength training result in shifting of cytokine expression toward anti-inflammation 
and diminished markers of oxidative stress.7,16,24,35,45 The benefit of early exercise in AIS and sICH in 
decreasing pro-inflammatory factors has been demonstrated in animal models when exercise is introduced 
between 24 hours and three days in AIS and at three or four days in sICH.40,53-55 An exercise intervention 
that is standardized in frequency with measureable intensity and duration is necessary to explore the effects 
of an exercise intervention in acutely ill patients with AIS and sICH. We hypothesize that a balancing of 
the inflammatory response after sICH can occur with the application of moderate exercise in the acute 
period.  
Objectives (include all primary and secondary objectives) 
 
Primary Objective: to determine the effects of twice-daily, lower extremity CE of 20 minutes duration 
plus usual care, compared to usual care alone, on the trajectories of M1 versus M2 cytokine phenotypes in 
the serum and cerebrospinal fluid (CSF). 
 
Secondary Objectives: 

 
 
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(i) To determine the effects of twice-daily, lower extremity CE of 20 minutes duration plus usual care 
compared to usual care alone and a third retrospective cohort of patients receiving usual care 
during the COVID-19 pandemic on, the immediate and sustained physical impairment, 
disability scores and relevant coavriates such as delirium and hospital acquired infections at 
NCCU discharge and 30 days after hemorrhage.  
(ii) To determine the correlation between serum and cerebrospinal fluid cytokines in patients with 
external CSF drainage as part of their care. 
(iii)To explore the relationship between pre-morbid physical function and quality of life and changes in 
inflammatory factors among all participants. 
(iv) To determine the effects of twice-daily, lower extremity CE of 20 minutes duration plus usual care 
alone on hemispatial neglect as measured by the Sunnybrook Neglect Assessment Procedure on 
day 1 of the study at transfer from the ICU or discharge from the hospital and 30 days after 
hemorrhage. 
 
2. 
Background (briefly describe pre-clinical and clinical data, current experience with procedures, 
drug or device, and any other relevant information to justify the research) 
 
There is an urgent need to develop interventions aimed at reducing the burden of severe disability in 
patients with sICH and AIS. Outcomes for patients with sICH have remained relatively stagnant and while 
outcomes after acute ischemic stroke have improved over the past several years with the widening of 
treatment windows for thrombolysis and use of thrombectomy the burden of disability after stroke in 
general remains high.4,14,36-37 
The innate immune response is triggered by the insult initiating a cascade of biochemical processes 
activating white blood cells, macrophages and microglia after a hemorrhagic ischemic insult.48-49,53 The 
initial immune response results in increased permeability of the blood brain barrier, cytokine expression, 
programmed neuronal death or apoptosis and culminates in brain tissue damage and loss of brain function. 
Cerebral inflammation likely contributes to morbidity and mortality through cerebral edema, cytokine and 
chemokine induced neuronal injury and thrombin associated toxicity.45-46 The expression of the pro-
inflammatory M1 cytokine phenotype predominates in the early period after sICH and is thought to worsen 
secondary brain injury. The anti-inflammatory M2 phenotype demonstrates a slower ascent to peak and is 
associated with tissue repair and hematoma degradation in sICH.45-46,55 Additionally, BDNF was been 
shown in animals to be produced in lesser amounts after sICH, potentially impeding repair and recovery.9,18 
Intervening to effect a balancing among M1 cytokines and M2 cytokines may increase the capacity for 
tissue repair. 
Animal and human studies have demonstrated that moderate intensity exercise when compared to 
exertional exercise or strength training result in a balancing of cytokine production and diminished markers 
of oxidative stress.16,24,35,40 An added benefit of early exercise in sICH was suggested by Takamatsu whose 
work demonstrated a decrease in IL1β and IL-6 and an increase in IL-10 with treadmill running within 4 
days of sICH in rats.40 Enhanced motor recovery was thought to be explained in part by enhanced neuronal 
plasticity using dendritic length as an endpoint.23 Zhang and colleagues demonstrated a reduction in pro-
inflammatory factors and anxiety behaviors in animal models with induced AIS.53 
 
An adaptable exercise intervention that is standardized in frequency with measureable intensity and 
duration is necessary to explore the effects of an exercise intervention in critically ill stroke patients. 
Accessibility of the intervention to patients with severe disability and altered levels of consciousness 
presents a challenge that can be overcome with in-bed cycle ergometry (CE) (see figure 1). Cycle 
ergometry is provided to patients by nurses or rehabilitation therapists with patients lying supine in bed by 
securing the lower extremities into supported pedals while motor driven rotations of the cycle move the 
legs passively. Active cycling can occur as a patient attempts to move their legs in a pedaling motion. Two 
recent trials of lower extremity CE reporting 963 sessions in critically ill medical patients cited a 0.6-2% 
rate of adverse events requiring termination of a cycling session, none requiring further intervention after 

 
 
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cessation of cycling.25-27,43 Cycle ergometry in critically ill patients with brain injury has been undertaken 
in a recent observational cohort study reporting no clinically significant changes in intracranial pressure or 
systemic hemodynamics.43 Further, our Neurocritical Care mobility group has compiled an unpublished 
dataset, consisting of 39 CE sessions in 39 patients with intracranial pressure monitoring that demonstrates 
no clinically significant changes in intracranial pressure, hemodynamics or neurologic status.28 Studies of 
cycle ergometry to date have reported on rehabilitation therapist delivery of cycle ergometry in durations of 
20-30 minutes, which due to resource constraints is usually delivered once per day.6,25-27,43, Our unit has 
established a practice where nurses also deliver this intervention while closely monitoring neurologic and 
hemodynamic status allowing for more than one session to be delivered.  Recent studies of CE in critically 
ill patients, including patients with neurologic illness, reported that cycling did not adversely affect 
hemodynamics or intracranial pressure.6,8,25-27 
 
Enrollment of subjects within the original study framework was put on hold beginning on March 
16, 2020 due to the necessary hospital response to prevent further spread of COVID-19 and to maximize 
reosurces to treat hospitalized patients. Adding a second control group where all variables except for 
biologic and survey data will allow comparison of three different care conditions, intervention plus usual 
care, usual care only and usual care only during a pandemic. Usual care in terms of study visit timing, 
number, and length may be different than pre-pandemic care paradigms due to staff redeployment and 
restructuring are care areas to support care during a disaster.    
3. 
Study Procedures 
a. Study design, including the sequence and timing of study procedures   
(distinguish research procedures from those that are part of routine care). 
 
 
This pilot study uses a randomized parallel group design to determine the difference in the 
expression of pro- and anti-inflammatory cytokines in response to this specific exercise intervention plus 
usual care versus usual care only. Patients will be enrolled on day 3 of illness and data will be collected for 
seven consecutive days. We seek to enroll a convenience sample of up to 100 consecutive patients with 
supratentorial sICH and acute ischemic stroke admitted to the Johns Hopkins Hospital Neurosciences 
Critical Care Unit (NCCU). Patients will be screened within 24-48 hours of arrival for eligibility according 
to the inclusion and exclusion criteria listed below. Informed consent will be obtained from the patient or 
legally authorized representative (LAR). The consenting process will be performed remotely via 
videoconference when possible.  
 
Patients will be randomly assigned to the intervention plus usual care or usual care only group 
using  a standard randomization schema generated by STATA 14.0 (College Station, Texas). The AIS and 
sICH cohorts will have separate randomization schemas.  
 
After enrollment, the Patient-Reported Outcomes Measurement Information System (PROMIS) 
Glabal Measure of Health v1.2 questionnaire for (pre-morbid health) will be administered to the patient or 
their LAR depending on the patient’s ability to complete the form. At the last follow-up visit the patient or 
LAR will complete the Stroke Impact Survey. Additionally, the Sunnybrook Neglect Assessment 
Procedure will be administered to the patient on day 1 of the study, on transfer from the ICU or discharge 
from the hospital and at 30 days after the hemorrhage.31 If the patient is assessed as not having neglect at 
the time of enrollment or is found not to have neglect as measured by the assessment procedure then they 
will not have to complete this measure at subsequent time points. 
 
The intervention group will receive two CE sessions per day after randomization with a unit 
owned cycle (Reck Motomed Letto, Germany). Sessions will be 
held at least 2hours apart to allow for patient rest and activities 
of patient care. The clinician will set the device to an automatic 
program where passive cycling will be initiated and the device 
will provide resistance if the patient attempts to actively cycle. 
Vital signs (e.g., heart rate, blood pressure, pulse oximetry, 
intracranial pressure) will be monitored continuously by a study 
team member present at the bedside during the CE session, if an 

 
 
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arterial line is not available the non-invasive cuff will be cycled every 5 minutes. Continuous vital signs 
will be extracted from the Sickbay software application, which collects physiologic data on all NCCU (see 
IRB00132987 Multimodality Neuromonitoring in the Neurocritical Care Unit). A clinician will observe the 
patient at all times during the session for signs of pain and discomfort and will administer the behavioral or 
visual analog pain scale every 5 minutes during the session depending on the patient’s level of 
consciousness. Patient tolerance will be defined as the absence of the following: decline in neurological 
examination; sustained change in intracranial pressure, blood pressure, heart rate or oxygen saturation 
outside of prescribed goals per established patient specific plan of care; an increase in pain as measured by 
the behavioral pain scale or numeric pain rating scale not easily ameliorated by position change by the 
clinician; and accidental tube/device/catheter removal.22,34 Manual muscle strength testing using the 
Medical Research Council Sum Score will be performed by a clinician before the first session on days three 
and seven for patients in the control group. General strength will be assessed using a hand-held 
dynamometer for patients able to follow simple commands before the first session on days three and seven 
for patients in the control group. Other relevant covariates will be extracted from the medical record such 
as delirium screening, hospital acquired infections, volume of hematoma and cerebral edema on routine CT 
scans and body temperature.  
 
The second control group, retrospective observational cohort, will consist of ischemic and 
hemorrhagic stroke patients admitted to the NCCU on the Johns Hopkins Hospital and Johns Hopkins 
Bayview campuses from March 16, 2020 through the end of the prohibition of tier II and III studies 
declared by the Johns Hopkins University Institutional Review Board. All data collection will be 
accomplished through retrospective chart abstraction. Face-to-face contat will not be required. The same 
clinical variables will be collected for this cohort to the extent that they are recorded in the medical record 
from admission to 90 days after the initial ischemic or hemorrhagic stroke. 
The following samples will be obtained for the intervention + usual care group and the control group, usual 
care only: 
a) A 2 teaspoon sample of the patient’s serum on the day of enrollment and two additional 
times during the seven day study period timed with routine collection of blood, when 
possible, for daily blood tests while the patient is in the hospital. Blood samples will be 
collected from an existing arterial or central line or via venipuncture. The initial blood 
sample will be collected on study day 1 prior to cycling in the intervention group and 
between 8 am-12 pm in the control group. Subsequent samples will be drawn after the 
second cycling session and between 2 pm and 6 pm in the control group.    
b) A 4-5 mL sample of saliva on the day of enrollment and two additional times during the 
seven day study period. Saliva will be collected between 8 am-10 am in all participants and 
prior to the first cycling session of the day for the intervention group. 
c) A 4 mL sample of cerebrospinal fluid (CSF) on the day of enrollment and two additional 
times during the seven day study period timed with collection of other sampling, when an 
external ventricular drain is in place as a part of care. CSF sampling will occur in patients 
with an external ventricular drain inserted as part of their care and will end after 3 samples 
or when the drain is discontinued. Efforts will be made to time CSF sampling with planned 
sampling, if possible and sampling will be performed by a nurse or physician study team 
member trained in the skill as part of their job using aspetic technique. The initial CSF 
sample will be collected on study day 1 prior to cycling in the intervention group and 
between 8 am-12 pm in the control group. Subsequent samples will be drawn after the 
second cycling session and between 2 pm and 6 pm in the control group.    
 
All samples will be placed on dry ice, centrifuged and stored in a -70 degree Celsius freezer within 1 hour 
of obtaining the sample. Samples will be labeled with de-identified data (patient study number and date 
only). 
 

 
 
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Usual care in the NCCU consists of evaluation and treatment by physical and occupational 
therapists assigned to the neurosciences service when an order for evaluation and treatment is entered by 
medical providers. Patients may be seen up to 5 times per week depending on their level of participation 
and intensity of therapy required, however many patients with sICH particularly those in coma are treated 
by therapists 2 times per week. Nursing staff in the NCCU provide passive range of motion and progressive 
a patient’s mobility from supine to upright positioning, sitting at the side of bed, transferring to chair, lift 
assisted transfer to chair and ambulation as the patient’s condition allows. All usual care activities will be 
recorded by the study team via extraction from the medical record. Usual care during the pandemic is 
similar to the care described above however, due to resource constraints it is possible that care focused on 
mobility and recovery was reprioritized in order to provide acute and intensive care for other patients. 
 
 
 
 

 
 
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Table 1. Study Activities Schedule for the intervention and prospective control group  
 
 
Admission 
day 1-2  
Study day 
1 = 
hospital 
day 3 
Study day 
2 = 
hospital 
day 4 
Study day 
3 = 
hospital 
day 5 
Study day 
4 = 
hospital 
day 6 
Study day 
5 = 
hospital 
day 7 
Study day 
6 = 
hospital 
day 8 
Study day 
7= 
hospital 
day 9 
Day of 
ICU 
transfer  
30 days 
after 
hemorrhage 
(-10, +30 
days) 
Screening, 
Inclusion/ 
Exclusion, 
Consent 
X 
 
 
 
 
 
 
 
 
 
Intervention and monitoring 
Cycle 
ergometry 
20 minute 
sessions 
(twice each 
study day) 
 
XX 
XX 
XX 
XX 
XX 
XX 
XX 
 
 
Vital signs 
(BP, HR, RR, 
SpO2, ICP) 
 
X 
X 
X 
X 
X 
X 
X 
 
 
Pain scores  
 
X 
X 
X 
X 
X 
X 
X 
 
 
Physiologic outcomes for the intervention and control groups 
Blood draw 
(IL1-β, IL-6, 
TNF-α, IL-
10, CRP, 
BDNF) 
 
 
X  
 
X 
 
 
 
 
X 
 
 
 
Saliva 
sample for 
cortisol  
 
X 
 
 
X 
 
 
 
 
X 
 
 
 
CSF 
sampling, if 
a external 
ventricular 
 
X 
 
 
X 
 
 
 
 
X 
 
 
 

 
 
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drain is in 
place 
Outcome measures 
Medical 
Research 
Council Sum 
Score 
(strength 
testing)21 
 
X  
 
X  
 
 
 
X  
X 
 
X 
 
Grip 
strength  
 
X 
 
 
X 
 
 
 
 
X 
 
X  
X 
Modified 
Rankin scale 
score 
X  
 
 
 
 
 
 
 
X 
X 
Barthel 
Index12 
 
 
 
 
 
 
 
 
X 
X 
Sunnybrook 
Neglect 
Assessment 
Procedure 
(SNAP)31 
 
X 
 
 
 
 
 
 
X This 
battery will 
only be 
completed 
if the 
patient was 
found to 
have 
neglect on 
the initial 
assessment. 
X This battery 
will only be 
completed if 
the patient 
was found to 
have neglect 
on the initial 
assessment. 
Questionnaires 
Promis 
Global 
Measure of 
Health v1.2 
to patient or 
legally 
authorized 
representativ
e (LAR) 
 
X 
 
 
 
 
 
 
 
 
Stroke 
 
 
 
 
 
 
 
 
 
X 

 
 
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Impact 
Survey to 
patient or 
LOR 

 
 
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b. Study duration and number of study visits required of research participants. 
The study will enroll patients for approximately two years. Each patient will receive study interventions or 
procedures depending on group assignment for 7 days, assessment of motor function and physical/cognitive 
functioning on transfer from the NCCU or 1 day after the last study day if the patient completed study 
activities outside of the NCCU  and 30 days (-10 days, +30 days) after occurrence of sICH. We will allow a 
30 day time period in which to contact the patient if they are not able to be contacted on the 30th day for a 
total study period of 60 days. If a patient is seen in clinic prior to the 30 day period after the hemorrhage, 
follow-up assessments will be performed at that time. The stroke service currently collects a modified 
Rankin score for all ischemic and hemorrhagic stroke patients at 90 days via phone as a standard of care. 
We will record this value for all patients in this study. If a patient is not scheduled for an in-person visit 
after discharge, only the 90 day modified Rankin scale will be collected as an outcome measure. 
c. Blinding, including justification for blinding or not blinding the trial, if applicable. 
This pilot trial cannot be blinded because of the use of the supine cycle ergometer which is a large piece of 
equipment introduced into the patients’ rooms in the intervention group twice per day during the initial 
study period, however outcome measures at NCCU transfer and 30 days will be obtained by a study team 
member blinded to the participant’s group assignment. 
d. Justification of why participants will not receive routine care or will have current therapy 
stopped. 
Current therapy will not be stopped. Participants will receive the study intervention in addition to usual 
care. 
e. Justification for inclusion of a placebo or non-treatment group. 
In order to detect a signal of cytokine modulation with the intervention regimen of supine cycle ergometry, 
a control group not receiving the intensive intervention regimen is necessary for comparison. 
f. Definition of treatment failure or participant removal criteria. 
If a patient meets the following stopping criteria on >2 consecutive sessions the patient will be withdrawn 
from the study: change in neurological examination, sustained change in intracranial pressure, blood 
pressure, heart rate, or oxygen saturation that is outside of provider-prescribed range, significant pain 
exacerbated by mobilization.22,34 
g. Description of what happens to participants receiving therapy when study ends or if a 
participant’s participation in the study ends prematurely. 
Upon study procedure completion participants will continue to receive usual care. 
 
4. 
Inclusion/Exclusion Criteria 
 
Inclusion criteria: 
Rationale: 
Age >18 years 
Spontaneous intracerebral hemorrhage and acute 
ischemic stroke is typically a disease of the adult.  
Supratentorial intracerebral hemorrhage with or 
without intraventricular hemorrhage 
Only patients with a supratentorial ICH will be 
included due to the fact that patients with 
infratentorial ICH often require surgery, introducing 
an overlay of inflammation above that which is 
caused by the ICH itself. It is known that 
intraventricular hemorrhage increases severity of 
illness and mortality, however it is a common co-
occurring process in patients with ICH and should 
be studied concurrently.13 
Acute ischemic stroke with a Medical Research 
Council Sum Score (MRCSS) of <27.  
Patients with a clinical diagnosis of stroke and 
motor weakness as identified by the MRCSS as less 
than 27.21 
Pre-morbid modified Rankin Score of 0-2 
The modified Rankin Score (mRS) is a commonly 

 
 
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used tool to quantify disability after stroke and is 
scored from 0 to 6 with higher scores describing 
increased disability including death. The mRS will 
be used to characterize a patient’s pre-morbid 
functional status correlating with a patient’s 
potential for recovery after stroke as well as an 
outcome measure at discharge and 30 days after 
hemorrhage.5,13 Patients with a mRS >2 prior to 
admission have poor potential for recovery.  
Patient must be able to provide informed consent or 
have a legally authorized representative to provide 
consent on their behalf 
 
Exclusion criteria: 
 
Patients with known inflammatory conditions, 
infection requiring antibiotics or pregnancy 
Underlying inflammatory disorders such as, but not 
limited to, rheumatoid arthritis, Lupus and 
fibromyalgia and pregnancy will impact 
interpretation of inflammatory biomarkers. Patients 
with a diagnosed infection requiring antibiotics 
(e.g., bacteremia, pneumonia, urinary tract 
infection) at the time of screening will be excluded 
due to associated systemic inflammation.  
Patients receiving daily anti-inflammatory 
medications including but not limited to prednisone, 
methotrexate, non-steroidal anti-inflammatory 
medications (ibuprofen, naproxen, indomethacin, 
celecoxib) and aspirin >325mg.  
These anti-inflammatory medications will adversely 
impact our ability to interpret inflammatory 
markers. 
Glasgow Coma Score (GCS) 3 48 hours after 
admission.  
A GCS of 3 represents the deepest form of coma 
wherein no response can be elicited from the patient 
in terms of eye opening, verbal output and motor 
response. A GCS of 3 on admission portends a poor 
outcome.41  
Patients in whom withdrawal of life support is being 
considered by surrogate decision makers. 
These patients are likely to die prior to or shortly 
after randomization. In the event that a surrogate 
elects not to withdraw life support, the patient will 
be reassessed for eligibility once more within 72 
hours of the ictus. 
Injury to the lower extremities, hips or pelvis, 
weight >250 kg (weight limit of cycle), or body 
habitus precluding normal function of cycle. 
These injuries or physical characteristics may make 
the cycling activity unsafe. 
 
5. 
Drugs/ Substances/ Devices 
a. The rationale for choosing the drug and dose or for choosing the device to be used. 
The cycle ergometer (CE) is capable of facilitating movement of the upper and lower extremities regardless 
of the participant’s ability to participate, therefore making it possible for use in patients with varying levels 
of consciousness and physical impairment. The CE is currently used by Rehabilitation Therapists and 
nurses as part of rehabilitative therapy in some NCCU patients. 
b. Justification and safety information if FDA approved drugs will be administered for non-FDA 
approved indications or if doses or routes of administration or participant populations are 
changed. 
No medications will be administered. 

 
 
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c. Justification and safety information if non-FDA approved drugs without an IND will be 
administered.  
No medications will be administered. 
 

 
 
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 Study Statistics 
a. Primary outcome variable. 
Pro-inflammatory cytokines: IL-1β, TNFα, IL-6; Anti-inflammatory/repair factors: IL-10, BDNF 
b. Secondary outcome variables will be measured at discharge and 30 days post-intracerebral 
hemorrhage or acute ischemic stroke. 
• Modified Rankin Scale (mRS)  
• Barthel Index will be measured at discharge and 30 days 
• Medical Research Council Sum Score and dynamometry to measure muscle strength 
• Discharge location (e.g., home, nursing facility), although not well studied, is commonly associated 
with physical function at discharge. 
• SF-12 
• Vital signs (e.g., heart, rate, blood pressure, respiratory rate) 
• Delirium positive days 
• Hospital acquired infections (e.g., catheter associated urinary tract infection and central line associated 
blood stream infection) 
• CSF cytokines and repair factors 
• Stroke Impact Survey 
 
c. Statistical plan including sample size justification and interim data analysis. 
 
Sample size was calculated for a fully powered trial and 9% of this sample size will be used for this 
pilot according to Cocks’ methodology.10 An effect size of 0.28 was used, based on a published single 
group observational study in critically ill patients with a primary outcome of cytokine change.47  Detection 
of an effect size of 0.28 with power of 80% and an α of 0.05 requires a sample size of 400 for a full trial 
and 9% represents a pilot sample size of 36 participants. Due to the enrollment of two stroke phenotypes, 
ischemic and hemorrhagic, we will analyze each cohort separately, therefore 40 participants per cohort are 
required. Accounting for attrition, up to 100 participants may be consented in order to enroll up to 40 
participnats per cohort. Each cohort will have 20 participants in each of two arms, intervention and control. 
It is estimated that at least 3-5 patients will be enrolled per month over 18 months. 
Descriptive statistics will be used to report sociodemographic variables. Baseline characteristics will be 
compared between the two groups. If they are found to be similar, post-intervention outcomes will be 
compared between the groups. If the baseline characteristics are found to be different, an adjusted analysis 
as described below will be conducted. Mean (SD) or median (IQR) will be used to describe continuous 
variables, and frequency (%) will be used for categorical variables. Mean differences in cytokines between 
the three time points (baseline, day 3 and day 7) will be calculated for each participant in the intervention 
and control groups. We will also plot data over time by group. Assumptions of normality will be checked 
and appropriate parametric or non-parametric tests will be used to detect absolute mean differences due to 
the small sample size, with an a priori significance level of 0.05, although the primary aim of this study is 
to estimate effect size. Data quality will be ensured by analyzing all samples in duplicate and procurement 
of samples will be performed by the same investigator. Statistical analysis will be performed using Stata 
14.0 (College Station, Texas). 
 
Primary aim (1): To determine whether a regimen of twice daily 20-minute sessions of CE plus usual care 
administered to patients with sICH and AIS (n=20) increases cytokines of the M2 phenotype and decreases 
cytokines of the M1 phenotype within 10 days of sICH when compared to a similar group of patients with 
sICH receiving usual care only (n=20). 
 
The effect size, absolute difference between the two groups and the standard error of the difference 
will be estimated. The standardized difference will be estimated using Cohen’s d. A two-sample t-test will 
be used to detect differences between post-test outcomes. If the baseline outcome is different, an analysis of 
covariance (ANCOVA) will be used to compare the outcomes between the two groups adjusting for the 
baseline difference as a covariate. 

 
 
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Hypothesis: Patients in the CE group will demonstrate an increase in cytokines of the M2 phenotype and a 
decrease in the M1 phenotype when compared to the group receiving usual care only. 
Aim 2: To determine the effects of twice-daily, lower extremity CE of 20 minutes duration plus usual care 
compared to usual care alone and a third retrospective cohort of patients receiving usual care during the 
COVID-19 pandemic on, the immediate and sustained physical impairment and disability scores at NCCU 
discharge and 30 days after hemorrhage.   
 
Data from this aim will be analyzed in the same fashion as described above. 
Hypothesis: The CE group will demonstrate decreases in 90-day modified Rankin Scale score, increases in 
the Medical Research Council sum score (muscle strength) and grip strength, less delirium positive days 
and hospital acquired infections.  
d. Early stopping rules. 
If a patient meets the following stopping criteria on >2 consecutive sessions the patient will be 
withdrawn from the study: change in neurological examination, sustained change in intracranial pressure, 
blood pressure, heart rate, or oxygen saturation that is outside of provider-prescribed range or significant 
pain exacerbated by mobilization. 
6. 
Risks 
a. Medical risks, listing all procedures, their major and minor risks and expected frequency. 
The risks of this study are designed to be minimal. Potential risks to the participant include the 
following: hemodynamic instability, increased intracranial pressure, skin breakdown associated with the 
supine cycle ergometer, pain, muscle spasm and musculoskeletal injury. 
 
b. Steps taken to minimize the risks. 
Patients are continuously monitored on a cardiorespiratory monitor with oxygen saturation, heart rate, 
intracranial pressure (when applicable) and blood pressure, measured by arterial catheter or non-invasive 
cuff. Blood pressure, heart rate, oxygen saturation, respiratory rate and intracranial pressure will be 
measured and recorded continuously using the Medical Informatics, Sickbay software application currently 
installed in the NCCU and collecting data from all cardiorespiratory monitors. Pain will be measured and 
documented every 5 minutes visual analog scale or behavioral pain scale in patients unable to report pain 
level. 
The NCCU is staffed 24 hours per day by a dedicated team of Neuro Intensivists, fellows and resident 
physicians assigned exclusively to the unit who can respond immediately to physiologic changes or adverse 
events when notified. A chain of command is followed when a primary provider is not available to respond 
due to other emergent patient care duties.  
Administration of cycle ergometry will be performed by the Principal Investigator or trained registered 
nurses (RN) who currently perform this therapy in the NCCU and have been trained in current personal 
protective equipment standards in the setting of the novel Coronavirus pandemic. These clinicians are in 
possession of reusable face shields and masks as part of their routine work. All clinicians performing the 
intervention will have documented competency using a standardized competency checklist including 
physiologic monitoring considerations, positioning and alignment of the patient in the cycle ergometer and 
considerations for the management of lines and tubes to mitigate risk of dislodgement. The applicant will 
observe the application and performance of CE performed by unit RNs during 10% of sessions to assure 
correct procedure. All procedures for applying the CE to the patient will be explained to the patient or 
family member(s) in attendance. A physical therapist is part of our study team and will provide consultation 
as needed regarding cycle ergometry.  Standard disinfection of the ergometer, inclusive of current 
guidelines for prevention of Coronavirus transmission, will be performed at the conclusion of each session 
by the study team.  
A recent prospective safety and feasibility study of supine cycle ergometry in critically ill patients 
found only one adverse event in 541 sessions (181 patients), dislodgement of a radial arterial line. Another 
recent prospective study of 20 patients in an NCCU with intracranial pressure monitoring, 3 of which had a 
diagnosis of sICH, found no significant increases in intracranial pressure. Since, cycle ergometry is 
currently available in the NCCU, we performed an internal retrospective evaluation of 23 patients with an 

 
 
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intraventricular catheter (intracranial pressure monitor) over 32 sessions receiving supine lower extremity 
cycle ergometry. This evaluation revealed no peripheral oxygen desaturation, hemodynamic instability and 
no increases in intracranial pressure requiring an end to the session or further treatment. 
Procurement of blood specimens will occur in tandem with standard of care blood draws (phlebotomy 
or arterial line) when possible and will be drawn by the applicant or the registered nurse caring for the 
patient. CSF specimens will be obtained using a protocol developed by the sponsor for a previous clinical 
trial requiring CSF sampling from an external ventricular drain. 
 
Plan for reporting unanticipated problems or study deviations.  
c. Legal risks such as the risks that would be associated with breach of confidentiality. 
Breaches in confidentiality will be reported to the IRB immediately by the PI. All data will be  
            stored in files on secured servers of the Johns Hopkins Hospital. 
d. Financial risks to the participants. 
          There are no financial risks to participants. 
 
7. 
Benefits 
a. 
Description of the probable benefits for the participant and for society 
 
There is no direct benefit to participants but participation may help future patients. Participants in 
the intervention arm of the study may benefit from increased attention by the study team during twice-
daily visits for the 7-day duration of the intervention period. The proposed study has the potential to lead 
to further investigations, which may be associated with improved functional outcome in this devastating 
disease process. 
 
8. 
Payment and Remuneration 
a. 
Detail compensation for participants including possible total compensation, proposed bonus, 
and any proposed reductions or penalties for not completing the protocol. 
There will be no remuneration to participants or their legally authorized representatives and  
           withdrawal from the study will not affect the participant’s care or legally authorized representatives  
           in any way. 
 
9. 
Costs 
a. 
Detail costs of study procedure(s) or drug (s) or substance(s) to participants and identify 
who will pay for them. 
There will be no cost of participation to the participant. Study assays and administration of the  
             intervention will be supported by a foundation grant from the Zach Sowers Brain Injury Research  
             Fund, The Scholl Foundation and in kind support of investigator time from the Johns Hopkins  
             Hospital. 
 
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