Abstract
Objective
This paper aims to assess the clinical effectiveness of an Enhanced Recovery After Surgery (ERAS)-based care bundle in facilitating early rehabilitation in patients with acute ischemic stroke (AIS).
Methods
A total of 120 AIS patients were randomly assigned to either a control group (n = 60), receiving routine nursing care, or an experimental group (n = 60), which received additional ERAS-guided bundled care. Outcome measures included neurological function [NIH Stroke Scale (NIHSS), modified Rankin Scale (mRS)], limb strength (Lovett scale), language ability [Boston Diagnostic Aphasia Examination (BDAE)], swallowing function [Water Swallow Test (WST)], psychological status [Hamilton Depression Rating Scale (HAMD), Hamilton Anxiety Rating Scale (HAMA)], and quality of life [Stroke-Specific Quality of Life Scale (SS-QOL)]. Incidence of adverse events was also recorded.
Results
Post-intervention, NIHSS and mRS scores declined more markedly in the experimental group than in the control group (P < 0.05). The experimental group had a higher number of patients with Lovett muscle strength grade 4, BDAE grades 4 and 5, and WST grade 1 compared to the control group (P < 0.05). The HAMD and HAMA scores in the experimental group were lower than those in the control group (P < 0.05). The experimental group also had lower adverse event rate compared to the control group (P < 0.05).
Conclusion
An ERAS-based care bundle can significantly enhance early functional recovery, mitigate psychological distress, and reduce complications in AIS patients, supporting its clinical applicability in stroke rehabilitation.
Keywords: Acute ischemic stroke, Enhanced recovery after surgery, Care bundle, Neurological function, Rehabilitation, Psychological status, Quality of life
Introduction
Ischemic stroke occurs due to a reduction or interruption of cerebral blood flow, often resulting from thrombosis or embolism, and can manifest acutely, subacutely, or chronically. Clinical presentations vary but commonly include dizziness, visual disturbances, facial asymmetry, limb weakness, and dysarthria [1, 2]. Early management of acute ischemic stroke (AIS) focuses on reperfusion strategies—such as intravenous thrombolysis and endovascular thrombectomy—which have demonstrated significant improvements in functional outcomes at 90 days post-onset [3]. Intravenous administration of alteplase remains the gold standard for thrombolytic therapy in eligible AIS patients [4]. Guidelines from major neurological societies recommend care in specialized stroke units and timely administration of recombinant tissue plasminogen activator (rtPA) as critical quality indicators for AIS management [5]. Given the complexity and duration of AIS rehabilitation, comprehensive nursing interventions play a pivotal role in facilitating recovery and promoting reintegration into daily life [6].
The Enhanced Recovery After Surgery (ERAS) program, pioneered by Wilmore and Kehlet, offers a paradigm shift in perioperative care by implementing evidence-based strategies that minimize physiological stress, expedite recovery, and support early mobilization [7]. Initially adopted in colorectal surgery, ERAS protocols have since been successfully extended to a wide range of surgical fields—including hepatobiliary, urologic, gynecologic, and pediatric specialties—as well as intensive care settings [8, 9]. Beyond improving clinical outcomes such as reduced opioid consumption, lower complication and readmission rates, and shorter hospital stays, ERAS has also enhanced patient satisfaction and postoperative functional status [10]. However, the surgical concept of ERAS, centered on “reducing stress and accelerating recovery” [11], has not yet been systematically applied in the rehabilitation management of patients with AIS, leaving a gap in the interdisciplinary transfer of experience. Complementing the ERAS framework is the care bundle approach, conceptualized by the Institute for Healthcare Improvement. A care bundle consists of three to five evidence-based practices performed collectively and reliably to improve patient outcomes. The simplicity, operability, and standardization of bundled interventions make them ideal for enhancing nursing care quality [12].
The novelty of this study lies in the systematic introduction of the surgical concept of ERAS, centered on “reducing stress and accelerating recovery,” into the nursing field of AIS and the construction of a bundled care strategy. We hypothesize that this structured program can synergistically optimize the rehabilitation process through multi-target interventions, ultimately improving functional outcomes, alleviating psychological distress, and reducing complications. This study aims to verify the comprehensive effects of this integrated program and provide evidence-based support for the development of a standardized early rehabilitation nursing pathway for stroke.
Materials and methods
Ethics statement
The study was reviewed and approved by the Medical Ethics Committee of Chongqing Traditional Chinese Medicine Hospital, and all study subjects and their families were informed and signed the informed consent form.
Participants
The study was conducted at the Neurocritical Care Unit of Chongqing Traditional Chinese Medicine Hospital. The patients diagnosed with AIS and admitted to the hospital between January 2022 and December 2024 were screened and enrolled.
The inclusion criteria were as follows: ① Diagnosis confirmed in accordance with the American Heart Association (AHA) criteria for AIS [13] and validated via cranial CT/MRI; ② Age between 18 and 80 years; time from onset to hospital admission ≤ 48 h; ③ Hemodynamically stable after initial treatment, with clear consciousness and ability to cooperate with rehabilitation; ④ NIH Stroke Scale (NIHSS) score between 5 and 20 points; ⑤ First-ever stroke with no history of myocardial infarction, respiratory failure, or other severe comorbidities; ⑥ Complete clinical data available; ⑦ Written informed consent obtained; study approved by the hospital ethics committee.
The exclusion criteria were as follows: ① Hemorrhagic stroke, transient ischemic attack (TIA), or other cerebrovascular conditions; ② Severe cardiac, hepatic, or renal insufficiency, or malignant tumors; ③ History of psychiatric illness or cognitive impairment; ④ Severe dysphagia requiring prolonged nasogastric feeding or tracheotomy; ⑤ Pre-existing limb disability or significant motor dysfunction; ⑥ Participation in other clinical trials or early withdrawal from this study; ⑦ Poor compliance preventing completion of rehabilitation.
Randomization and masking
After enrollment, eligible patients were randomly assigned in a 1:1 ratio (Fig. 1). In the randomization process, each participant was assigned a serial reference number generated by a computer. These numbers remained undecoded until the intervention group assignment. An offsite statistician, an independent team member not involved in enrollment, intervention, or assessments, conducted the randomization process. Participants and research assistants responsible for assessment and data analysis were blinded to the group allocation.
Fig. 1.
Flow diagram of the study
Intervention protocols
Patients in the control group were given the routine nursing care, including:
(1) Basic medical care: ① Condition monitoring: Vital signs (blood pressure, heart rate, blood oxygen saturation) were measured every 2 h. Consciousness state and pupil change were documented; ②Medication management: Antiplatelet agents (aspirin/clopidogrel), statins, and cerebral circulation-improving drugs (e.g., butylphthalide) were administered per physician orders; ③ Complication prevention: Patients were turned and given back pats every 2 h; air mattresses were used to prevent pressure ulcers. Intermittent pneumatic compression (IPC) was applied twice daily to prevent deep vein thrombosis (DVT). (2) Basic rehabilitation guidance: ① Position management: Proper limb positioning was ensured to avoid pressure on the affected side, with repositioning performed three times daily; ②Passive joint mobilization: A rehabilitation therapist performed passive range-of-motion exercises for the shoulders, elbows, knees, and ankles once daily, 20 min per session. (3) Health education: Stroke rehabilitation manuals were distributed. Verbal education covered disease knowledge and dietary guidance, emphasizing low-salt, low-fat diets.
Patients in the experimental group, in addition to receiving routine care (with care content identical to that of the control group), also underwent bundled nursing strategies based on the ERAS concept. The specific bundled nursing strategies under the ERAS concept are as follows:
(1) Early rehabilitation intervention (initiated within 24 h of admission): ① Neuroprotection: The head of the bed was elevated 15°–30° to ensure cerebral perfusion, avoiding excessive flexion or extension of the neck. Body temperature was maintained below 37.5 °C; physical cooling was applied as necessary; ② Active rehabilitation: For conscious patients, in-bed exercises such as bridge movements and turning training were initiated within 48 h of admission, twice daily for 10 min per session. Language training (e.g., auditory comprehension and expression exercises) was delivered daily using picture cards and simple Q&A. Swallowing exercises included ice stimulation (posterior pharyngeal wall, base of tongue) and dry swallowing practice, performed three times daily. For comatose/lethargic patients, joint compression and acupressure for limb sensory stimulation were applied twice daily starting within 24 h. (2) Multimodal nutritional support: ① Swallowing function assessment: For Water Swallow Test (WST) grades 1–2: early oral feeding with semisolid food, small and frequent meals. For WST ≥ 3: enteral nutrition via nasogastric tube with short peptide-based formula, ≥ 25 kcal/kg/day; ② Nutritional monitoring: Serum albumin and prealbumin levels were measured weekly to adjust nutritional plans accordingly. (3) Stepped motor rehabilitation (stage-based): ① Acute phase (within 72 h of onset): Passive/active joint movements in bed and abdominal breathing exercises, twice daily; ② Subacute phase (72 h to 1 week): Sitting balance training and bedside standing using tilt tables, gradually transitioning to assisted walking; ③ Recovery phase (after 1 week): Instrument-assisted training (e.g., lower-limb ergometer, balance trainer) for 30 min daily; training in daily living activities (e.g., dressing, eating) once daily. (4) Psychosocial support: ① Anxiety and depression management: Mindfulness-based stress reduction (MBSR) group therapy three times per week; bedside communication with family-led psychological counseling for 15 min daily; ② Home rehabilitation education: Instructional videos were delivered via WeChat to guide families in assisting with turning and massage. (5) Bundle prevention of complications: ① DVT prevention: Graduated compression stockings (GCS) + IPC twice daily; subcutaneous low molecular weight heparin for high-risk patients; ② Pulmonary infection prevention: Postural drainage and vibration expectoration therapy twice daily; oral care with chlorhexidine mouthwash three times daily; ③ Spasm prevention: Neuromuscular electrical stimulation (NMES) of spastic muscles once daily; early antispastic positioning (wrist dorsiflexion, ankle neutral). (6) Multidisciplinary team (MDT) collaboration: ① Daily morning handover: Neurologists, rehabilitation therapists, dietitians, and nurses jointly set rehabilitation goals; ② Weekly MDT meetings: Progress was evaluated, and plans were adjusted accordingly (e.g., upgrading nutritional support or intensifying psychological interventions).
Both groups received continuous nursing intervention for two months, after which outcomes were compared.
Quality control
To guarantee the credibility of our findings, we implemented the following quality control measures: (1) Nursing staff and patient allocation: Throughout the trial, bedside nurses assigned to each group of patients were exclusively responsible for their respective patients, with no staff being transferred between the two groups. Additionally, patients from the two groups were placed in separate wards to minimize the potential impact of inter-patient communication on the accuracy of the final trial results. (2) Uniform training and assessment for evaluation consistency: To maintain homogeneity in evaluation, all team members underwent standardized training and assessment prior to the commencement of the trial. This ensured the precision of daily operations and assessment techniques. (3) Supervision and data management: The lead nurse oversaw and executed the entire trial. A designated individual was responsible for data collection. To ensure data accuracy, two separate individuals were tasked with data entry and statistical analysis, respectively. This approach helped verify the precision of both the collected data and the calculated results.
Outcome evaluation
The primary outcomes of this study were the NIHSS and modified Rankin Scale (mRS) scores. The secondary outcomes included the Lovett muscle strength grading, Boston Diagnostic Aphasia Examination (BDAE), WST, Hamilton Depression Rating Scale (HAMD), Hamilton Anxiety Rating Scale (HAMA) scores, Stroke-Specific Quality of Life Scale (SS-QOL) scores, and adverse events.
(1) Neurological function: NIHSS and mRS scores were compared before and after nursing care. NIHSS assesses consciousness, gaze, facial palsy, limb movement, ataxia, sensation, language, and neglect, with a total score range of 0–42; higher scores indicate more severe deficits [14]. mRS measures disability from 0 (no symptoms) to 6 (death) [15].
(2) Rehabilitation outcomes: Muscle strength: Evaluated using the Lovett scale: 0 (no contraction) to 5 (normal strength) [16]. Language function: Assessed using the BDAE, graded from 0 (global aphasia) to 5 (normal function) [17]. Swallowing function: Assessed via the WST, graded from 1 (no choking) to 5 (frequent aspiration and incomplete swallowing) [18].
(3) Psychological status: HAMD (0–68): Scores ≥ 8 indicate depression, with higher scores reflecting greater severity [19]. HAMA (0–56): Scores ≥ 7 indicate anxiety symptoms, with severity correlating with score level [20].
(4) Quality of life: Measured using the SS-QOL, with scores ranging from 49 to 245; higher scores denote better quality of life [21].
(5) Adverse events: Incidence of adverse events during the intervention was recorded, including falls, aspiration, orthostatic hypotension, pulmonary infection, urinary tract infection, DVT, pressure ulcers, recurrent stroke, and TIA.
Sample size estimation
Based on the results of a preliminary experiment and previous similar studies [22], using the NIHSS score as the primary observation indicator, G*Power software was employed. Setting 1-β (power) at 95% and α (significance level) at 0.05, and referring to the sample size estimation formula for comparing means between two independent samples, the minimum number of participants required was calculated, taking the maximum value. This resulted in at least 41 patients per group. Considering the potential for patient loss to follow-up, with a 20% loss rate as the standard, at least 49 patients per group were required, totaling 98 patients for both groups. During the clinical study, 120 patients were ultimately included.
Statistical analysis
Data analysis was conducted using SPSS version 27.0. Categorical variables were expressed as n (%) and compared using the chi-square test. The normality of the data was tested using the Shapiro-Wilk test. Normally distributed continuous variables were reported as mean ± standard deviation (SD) and analyzed using independent-samples or paired t-tests. Non-normally distributed data were reported as median and quartile spacing (P25, P75) and compared using the Mann–Whitney U test or Wilcoxon signed-rank test. A P-value < 0.05 was considered statistically significant.
Results
Baseline characteristics
Initially, 185 patients were recruited. After screening based on inclusion and exclusion criteria, 120 patients were ultimately selected. These 120 patients were randomly divided into the control group and the experimental group, with 60 patients in each group. No significant differences were observed in baseline characteristics between the two groups (P > 0.05), confirming their comparability (Table 1).
Table 1.
Comparison of baseline characteristics between groups
| Variable | Experimental group (n = 60) | Control group (n = 60) | χ2/Z/t | P |
|---|---|---|---|---|
| Gender [n (%)] | 0.301 | 0.583 | ||
| Male | 30 (50.00%) | 33 (55.00%) | – | – |
| Female | 30 (50.00%) | 27 (45.00%) | – | – |
| Age (years) | 64.50 (57.00, 71.75) | 62.50 (54.25, 71.75) | − 0.712 | 0.477 |
| BMI (kg/m²) | 24.27 ± 2.94 | 24.87 ± 2.81 | − 1.141 | 0.256 |
| Infarction site [n (%)] | 1.915 | 0.166 | ||
| Anterior circulation | 38 (63.33%) | 45 (75.00%) | – | – |
| Posterior circulation | 22 (36.67%) | 15 (25.00%) | – | – |
| Smoking history [n (%)] | 28 (46.67%) | 20 (33.33%) | 2.222 | 0.136 |
| Alcohol consumption [n (%)] | 16 (26.67%) | 22 (36.67%) | 1.386 | 0.239 |
| Hypertension [n (%)] | 40 (66.67%) | 34 (56.67%) | 1.269 | 0.260 |
| Diabetes mellitus [n (%)] | 22 (36.67%) | 14 (23.33%) | 2.540 | 0.111 |
| Hyperlipidemia [n (%)] | 18 (30.00%) | 25 (41.67%) | 1.776 | 0.183 |
| Education level [n (%)] | 0.543 | 0.909 | ||
| Primary school | 16 (26.67%) | 18 (30.00%) | – | – |
| Secondary school | 25 (41.67%) | 22 (36.67%) | – | – |
| High school | 13 (21.67%) | 15 (25.00%) | – | – |
| College or higher | 6 (10.00%) | 5 (8.33%) | – | – |
Neurological function indicators
Prior to nursing intervention, no significant differences were observed in NIHSS and mRS scores between the two groups (P > 0.05). However, after the nursing, both groups exhibited reductions in NIHSS and mRS scores, with the experimental group showing significantly lower scores in contrast to the control group (P < 0.05) (Table 2).
Table 2.
Comparison of neurological function scores between groups
| Indicator | Experimental group (n = 60) | Control group (n = 60) | Z | P |
|---|---|---|---|---|
| Pre-nursing | ||||
| NIHSS scores (score) | 12.00 (9.25, 15.00) | 12.00 (10.00, 14.00) | − 0.166 | 0.868 |
| mRS scores (score) | 3.00 (3.00, 4.00) | 3.00 (3.00, 4.00) | − 0.121 | 0.904 |
| Post-nursing | ||||
| NIHSS scores (score) | 7.00 (5.00, 8.00)* | 9.00 (7.00, 11.00)* | − 4.549 | < 0.001 |
| mRS scores (score) | 2.00 (2.00, 3.00)* | 3.00 (2.00, 3.00)* | − 4.959 | < 0.001 |
*P < 0.05 vs. pre-nursing within group
Limb muscle strength recovery
Baseline Lovett muscle strength grading showed no significant difference between the two groups (P > 0.05). Following the intervention, the experimental group demonstrated a notable improvement in muscle strength, with a significantly higher number of patients achieving grade 4 relative to the control group (P < 0.05) (Table 3).
Table 3.
Comparison of limb muscle strength recovery between groups [n (%)]
| Grade | Pre-nursing | Post-nursing | ||
|---|---|---|---|---|
| Experimental group(n = 60) | Control group (n = 60) | Experimental group(n = 60) | Control group (n = 60) | |
| Grade 0 | 10 (16.67%) | 8 (13.33%) | 0 (0.00%) | 3 (5.00%) |
| Grade 1 | 18 (30.00%) | 14 (23.33%) | 2 (3.33%) | 8 (13.33%) |
| Grade 2 | 20 (33.33%) | 22 (36.67%) | 9 (15.00%) | 18 (30.00%) |
| Grade 3 | 10 (16.67%) | 13 (21.67%) | 26 (43.33%) | 21 (35.00%) |
| Grade 4 | 2 (3.33%) | 3 (5.00%) | 16 (26.67%)* | 7 (11.67%) |
| Grade 5 | 0 (0.00%) | 0 (0.00%) | 7 (11.67%) | 3 (5.00%) |
| χ 2 | 1.200 | 12.250 | ||
| P | 0.753 | 0.009 | ||
*P < 0.05 vs. control group post-nursing
Language function
Before nursing intervention, BDAE grading was comparable between the groups (P > 0.05). Post-intervention, the experimental group exhibited a significant improvement in language ability, with more patients reaching grades 4 and 5 on the BDAE versus the control group (P < 0.05) (Table 4).
Table 4.
Comparison of Language function (BDAE classification) between groups [n (%)]
| Grade | Pre-nursing | Post-nursing | ||
|---|---|---|---|---|
| Experimental group(n = 60) | Control group (n = 60) | Experimental group(n = 60) | Control group (n = 60) | |
| Grade 0 | 9 (15.00%) | 7 (11.67%) | 0 (0.00%) | 3 (5.00%) |
| Grade 1 | 14 (23.33%) | 12 (20.00%) | 3 (5.00%) | 7 (11.67%) |
| Grade 2 | 22 (36.67%) | 24 (40.00%) | 11 (18.33%) | 22 (36.67%) |
| Grade 3 | 12 (20.00%) | 15 (25.00%) | 22 (36.67%) | 20 (33.33%) |
| Grade 4 | 3 (5.00%) | 2 (3.33%) | 18 (30.00%)* | 8 (13.33%) |
| Grade 5 | 0 (0.00%) | 0 (0.00%) | 6 (10.00%)* | 0 (0.00%) |
| χ 2 | 1.024 | 18.21 | ||
| P | 0.906 | 0.003 | ||
*P < 0.05 vs. control group post-nursing
Swallowing function
No remarkable differences were observed in WST grading at baseline between groups (P > 0.05). After nursing care, WST grades were significantly decreased in the experimental group, with a larger proportion of patients achieving grade 1 in comparison to the control group (P < 0.05) (Table 5).
Table 5.
Comparison of swallowing function (WST Grading) between groups [n (%)]
| Grade | Pre-nursing | Post-nursing | ||
|---|---|---|---|---|
| Experimental group(n = 60) | Control group (n = 60) | Experimental group(n = 60) | Control group (n = 60) | |
| Grade 1 | 6 (10.00%) | 8 (13.33%) | 27 (45.00%)* | 14 (23.33%) |
| Grade 2 | 12 (20.00%) | 11 (18.33%) | 18 (30.00%) | 20 (33.33%) |
| Grade 3 | 24 (40.00%) | 27 (45.00%) | 13 (21.67%) | 19 (31.67%) |
| Grade 4 | 15 (25.00%) | 12 (20.00%) | 2 (3.33%) | 7 (11.67%) |
| Grade 5 | 3 (5.00%) | 2 (3.33%) | 0 (0.00%) | 0 (0.00%) |
| χ 2 | 1.039 | 8.130 | ||
| P | 0.904 | 0.043 | ||
*P < 0.05 vs. control group post-nursing
Psychological status
There were no significant intergroup differences in HAMD and HAMA scores prior to the intervention (P > 0.05). After nursing care, both scores declined in both groups, with the experimental group demonstrating lower HAMD and HAMA scores than the control group (P < 0.05) (Table 6).
Table 6.
Comparison of psychological status (HAM-D, HAM-A scores) and quality of life (SS-QOL scores) between groups
| Indicator | Experimental group (n = 60) | Control group (n = 60) | Z | P |
|---|---|---|---|---|
| Pre-nursing | ||||
| HAM-D scores (score) | 16.00 (14.00, 19.00) | 16.00 (13.25, 18.00) | − 0.726 | 0.468 |
| HAM-A scores (score) | 14.50 (12.25, 17.00) | 14.00 (11.00, 16.00) | − 1.230 | 0.219 |
| SS-QOL scores (score) | 120.18 ± 17.96 | 118.43 ± 16.49 | ||
| Post-nursing | ||||
| HAM-D scores (score) | 7.00 (5.25, 9.00)* | 12.00 (9.25, 14.00)* | − 7.575 | < 0.001 |
| HAM-A scores (score) | 5.00 (4.00, 7.00)* | 10.00 (8.25, 12.00)* | − 8.682 | < 0.001 |
| SS-QOL scores (score) | 174.03 ± 18.70* | 147.28 ± 17.83* |
*P < 0.05 vs. control group post-nursing
Quality of life
Baseline SS-QOL scores were statistically similar between the groups (P > 0.05). After the two-month intervention, both groups showed improved SS-QOL scores, with the experimental group achieving higher scores versus the control group (P < 0.05) (Table 6).
Adverse events
The incidence of adverse events was markedly lower in the experimental group [11.67% (7/60)] than in the control group [26.67% (16/60)] (P < 0.05) (Table 7).
Table 7.
Comparison of adverse events between groups [n (%)]
| Adverse event | Experimental group (n = 60) | Control group (n = 60) | χ2 | P |
|---|---|---|---|---|
| Falls | 1 (1.67%) | 1 (1.67%) | - | - |
| Aspiration | 2 (3.33%) | 3 (5.00%) | - | - |
| Orthostatic hypotension | 2 (3.33%) | 4 (6.67%) | - | - |
| Pulmonary infection | 1 (1.67%) | 2 (3.33%) | - | - |
| Urinary tract infection | 1 (1.67%) | 2 (3.33%) | - | - |
| DVT | 0 (0.00) | 1 (1.67%) | - | - |
| Pressure ulcers | 0 (0.00%) | 1 (1.67%) | - | - |
| Recurrent stroke | 0 (0.00%) | 1 (1.67%) | - | - |
| TIA | 0 (0.00%) | 1 (1.67%) | - | - |
| Total | 7 (11.67) | 16 (26.67) | 4.357 | 0.037 |
Discussion
Li et al. have demonstrated that the emergence of a neurosurgical ERAS nutritional support program can effectively intervene in perioperative nutritional status and significantly reduce postoperative hospital stays [23]. This study provides robust evidence supporting the clinical effectiveness of an ERAS-based care bundle in improving early rehabilitation outcomes among patients with AIS. Compared with standard nursing care, the bundled approach yielded superior recovery across multiple domains—including neurological function, motor performance, language proficiency, swallowing ability, psychological well-being, and quality of life—while also reducing the incidence of adverse events. These results highlight the value of this nursing strategy in optimizing post-stroke recovery.
The significant reduction in NIHSS and mRS scores observed in the experimental group reflects more pronounced improvements in global neurological function. Interventions such as head-of-bed elevation, maintenance of normothermia, and early initiation of mobilization likely contributed to enhanced cerebral perfusion and the prevention of secondary neurological injury. Neuroplasticity—the brain’s inherent ability to adapt structurally and functionally following injury—is most dynamic in the early post-stroke period, providing a crucial window for intensive rehabilitation interventions [5]. Additionally, ERAS protocols advocate for early resumption of oral nutrition and prompt removal of catheters, both of which have been associated with shorter hospital stays without increased readmission risk [24]. Stroke recovery is also facilitated by multidisciplinary collaboration and patient-centered care, with education and individualized planning playing essential roles [6, 25]. Notably, bundle-based strategies targeting early physiological stabilization—such as blood pressure control—have shown efficacy in improving outcomes for acute intracerebral hemorrhage as well [26].
Regarding motor recovery, the higher proportion of patients achieving Lovett grade 4 muscle strength in the experimental group underscores the value of staged, progressive physical rehabilitation. The phased approach—beginning with passive and transitioning to active limb exercises—leverages the early plasticity of the motor cortex. Stroke-related motor impairment, particularly of the lower limbs, can benefit from targeted interventions within 24 to 48 h post-onset [27]. Physical therapy remains a cornerstone of stroke rehabilitation, capable of enhancing mobility, reducing disability, and improving quality of life [28, 29]. Comprehensive rehabilitation techniques—including range-of-motion training, cycling with functional electrical stimulation, and strength-building exercises—have been shown to improve endurance, balance, and overall function in stroke survivors [29]. These principles have also proven beneficial in perioperative care, as evidenced by improved outcomes in pediatric patients undergoing minimally invasive endoscopic procedures managed with care bundles [12].
The marked improvement in language and swallowing function among ERAS patients further supports the efficacy of integrated rehabilitative strategies. Regular, structured speech-language therapy and consistent swallowing exercises likely contributed to the observed gains. A significantly larger proportion of patients in the experimental group attained grade 1 on the WST, indicating restored safe swallowing capacity. Similar benefits have been reported in ERAS-informed recovery models for spinal metastasis surgery, where bundled interventions—including respiratory exercises and psychological support—were associated with improved short-term recovery and quality of life [30]. Additionally, protocols addressing hyperglycemia, fever, and dysphagia in the acute stroke setting have demonstrated improved patient outcomes [26].
Psychological recovery was also more pronounced in the experimental group. Incorporation of MBSR and daily family-assisted counseling helped alleviate emotional distress and reduce caregiver burden. Prior trials have shown that ERAS interventions can reduce pain, shorten hospitalization, and lower complication rates, including in orthopedic and urological surgeries [31, 32]. In adolescents undergoing scoliosis surgery, ERAS protocols have been shown to stabilize pain control and improve perioperative recovery trajectories [33]. Integrated care models with strong interdisciplinary collaboration have also demonstrated improved outcomes, including reduced depression and lower rates of stroke recurrence [34, 35].
Furthermore, the ERAS-based care bundle led to a substantially lower incidence of adverse events. Preventive strategies targeting DVT, aspiration, infections, and spasticity—implemented as part of the bundled approach—resulted in a nearly 15% absolute risk reduction in complications. Early mobilization has been shown to enhance pulmonary ventilation and venous return, mitigating the risks of pneumonia and thromboembolic events [5]. Prompt catheter removal reduces the likelihood of urinary tract infections, a benefit noted in both general surgical and stroke populations [36]. Moreover, ERAS implementation has consistently reduced postoperative complications across surgical specialties, including hepatobiliary and cardiac procedures [36, 37]. Critical care bundles in intensive care units have similarly emphasized infection control, safety, and quality improvement [38].
In conclusion, the study results indicate that the ERAS-based care bundle not only accelerates neurological and physical recovery in AIS patients but also reduces psychological distress and complications. This new approach underscores the potential of interdisciplinary strategies to redefine post-stroke rehabilitation standards, providing a replicable model for integrating systematic recovery programs into neurological care, which supports the novelty of this study. However, this study was a single-center study with a limited sample size, which may restrict the generalizability of the results. Additionally, our study did not conduct long-term follow-up, preventing a comprehensive assessment of the long-term benefits of the ERAS-guided care bundle. Future research could involve multi-center, large-sample studies with long-term follow-up to further refine and develop this nursing strategy.
Author contributions
L.Y. finished the study design. X.L.Z. finished the experimental studies. Q.H.P. finished the data analysis. Y.X.M. finished the manuscript editing. All authors read and approved the final version of the manuscript.
Funding
This study was funded by [Stroke Prevention and Control] Construction Funding for the First Batch of Key Public Health Specialties Project in Chongqing Municipality in 2025 (Yufinance and Social Security [2024] No. 1129).
Data availability
The experimental data used to support the findings of this study are available from the corresponding author upon request.
Declarations
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Li Yan and Xiaoli Zhou contributed equally to this work.
Contributor Information
Qihuan Pang, Email: PangQihuan385716@outlook.com.
Yangxi Mao, Email: MaoYangxi6708@163.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The experimental data used to support the findings of this study are available from the corresponding author upon request.