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ICU-Acquired weakness: Implications for PT
managementPresented By: Chris Grant SPTA
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Specific Manefestations
• Critical Illness Myopathy(CIM)• -proximal weakness• -Sensation intact
• Critical Illness Polyneuropathy(CIP)• -reduced DTR• -impaired pain, temp, vibration
• Critical Illness Polyneuromyopathy(CIPM)• -Electrodiagnostic testing• -Medical Research Council sum score <48
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MRC table
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Be aware of sedation
Sedation is going to mask ICU acquired weakness
A sedation vacation combined with early PT leads to shorter ICU stays.( Schweikert et al)
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prognosis
• Body systems, respiratory, renal, and cardiovascular systems typically resolve
• Neuromuscular impairments may take 6 -12 months to resolve
• In a Meta analysis by Latricio and colleagues out of 263 total pts only 68 % reported complete functional recovery. Even with “complete” recovery, foot drop or muscle atrophy was seen.
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Criteria for starting Physical Therapy
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Body structure and function
• A measurement of grip strength of <7kg in women and <11kg in men indicated ICU acquired weakness
• Mechanical ventilation for as little as 18 hrs altered force production and muscle atrophy in the diaphragm.
• Assessment of DTRs indicated because of CIP and CIM associated with altered reflexes.
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Tests and measures
• Several tests and measures provide insight into the patients activity limitations
• The FIM and the Physical Function in the ICU test (PFIT)• -Assistance from sit to stand• -Shoulder flexion and knee extension strength• -Marching in place• -Upper extremity endurance task shoulder
flexion to 90 deg
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PFIT
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Physical intervention
• Primary focus is on regaining ability to perform essential daily activities.
• Intervention tailored to if patient is fully awake, physiologically stable but functionally stable, or simply deconditioned
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techniques
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Specific interventions
• E-stim coupled with active exercises for those with COPD who were mechanically ventilated and initially unresponsive demonstrated greater strength gains and were able to transfer to a chair earlier.(Zanotti et al)
• Cycle ergometry was used with unresponsive patients along with general PT interventions. This lead to greater gains in quad strength and greater 6 minute walk test distance when compared with those who received standard PT (Burtin et al)
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Cycle ergometer
• Passive motion applied to sedated subjects and active motion to those who were conscious
• Pts received RT and cycle ergometer sessions. Median cycling average was 4 times per week at 20 minutes. • 20 consecutive minutes for sedated pts• 2 bouts of 10 minutes for conscious pts
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continued
• Respiratory Techniques• -Deep breathing, pursed lips, pacing of
breathing, inspiratory muscle training, assisted cough, and airway clearance techniques
• -These approaches have not been reported in people with ICU –acquired weakness but may prove useful to address effects of prolonged mechanical ventilation.
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How much Do we challenge Patients??
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Order of intervention
• Some therapist choose to start with easiest exercises and progress to more challenging ones
• Others choose the most difficult exercises when pts have the most amount of energy and strength
• The are merits to both, but there is insufficient data to determine which is more efficacious
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Frequency
• Dean,Perme and Chandrahekar describe an algorithm for ICU patients, not necessarily those with ICU-acquired weakness.
• Most acute patients were seen for 15-30 minutes 1-2 times daily.
• Sub acute patients were seen for 30-60 minutes 5-7 days per week.
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Questions
• ? ? ?
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Thank you