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Early rehabilitation in the ICU:
Beatrix Clerckx, PT
Department of Rehabilitation Sciences, Department of Intensive Care Medicine, University Hospitals Leuven,
KU Leuven Belgium
MOVE IT or LOSE IT
Truong Crit.Care 2009;13(4):216
(Pathophysiological mechanisms)
= ICUAW
Weaning failure
Emotional functioning
Deconditioning, Inactivity
+++ Sarcopenia: Low muscle mass, muscle strength, physical
performance
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Hermans et al. AJRCCM 2014
WEANING DISCHARGE ICU DISCHARGE HOSPITAL
ICUAW and clinical outcome
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ICUAW and survival
Hermans et al. AJRCCM 2014
Prolonged ICU stay often results in long term functional and cognitive impairment (5Y)
Herridge et al. NEJM 2011
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CHEST/144/3/SEPTEMBER 2013
Reck MOTOmed Movement Therapy Systems, Germany
Cycle programme(passive/active) 20’ per dayin addition to ‘Usual’ care
‘Usual’ care: respiratory physiotherapy mobilisation
Critically ill patient• 5 days ICU and forecastof another 7 days at the ICU
Burtin et al. CCM 2009; 37:2499-2505
Studie design
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TR CO TR CO1.0
1.5
2.0
2.5
3.0
ICU discharge hospital discharge
QF
(N
/kg
)
p < 0.01p < 0.05
Burtin C, CCM 2009
TR CO
0
100
200
300
400
500
600
p < 0.05
6MW
D (
m)
TR CO
10
15
20
25
30 p < 0.05
SF
-36
PF
sco
re (
10-3
0)
196 [126-329] m 143 [37-226] m
21 [18-23] points 15 [14-23] points
‘In general, the achieved absolute workload during cycling exercise wasvery low and HR, blood pressure, andrespiratory rate did not change’.
‘In general, the achieved absolute workload during cycling exercise was?:
A: very low B: very high
Frequently researched in highly specialized (university) centers
The feasibility and safety of early physical therapy in ICU patients
Nevertheless there are still perceived ‘barriers’ to facilitate rehabilitation on the ICU
Bourdin et al. Respir. Care 2010: 55:400
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Passive / active cycling
Is het mogelijk om met een gesedeerde patiënt te fietsen?A: Ja B: Nee
• Other material (‘Be creative’)• Team Work• Change in mentality (worldwide)• Mobility protocols
Solutions for barriers
Last decade > development of different mobility protocols(Morris et al. 2008, Schweickert et al. 2009)
> The proposition of the protocol is discussed, adapted and evaluated by multidisciplinary team members
UZ LEUVEN ‘Start to move asap’ protocol
UZ LEUVEN ‘start to move’ ASAP protocol (+/-2009)
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6-level program
deliver daily mobility or physical activity from day 2after admission to the ICU
each level is determined by assessment using objective measurements
each level consists of a variety of body positionsand modalities for physical training and early mobility
Is feeding another ‘barrier’ ?
What about underfeeding or overfeeding havingdeliterious consequences for critically ill patients?
Are combined, nutrition and exercise interventions, potential strategies to prevent or
attenuate ICUAW and associated functional impairments?
How can we optimize objectively the benefits of exercise efforts in ICU- critical ill patients?
Energy expenditure in the critically ill performing early physical therapy
• REE (resting energy expenditure) determination is of high relevance to avoid both overfeeding and underfeeding
• Patients are mobilized early
• No Recommendations exists to improve nutrition when early mobilization is performed
Hickmann C.E. et all Intensive Care Med (2014)40:548-555
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Methods
prospective observational study
- 49 hemodynamically stable critically ill patients
- 15 healthy volunteers
Indirect Calorimetry (V02, VC02)
Hickmann C.E. et all Intensive Care Med (2014)40:548-555
Rest Exercise at 0,3 or 6 Watt Rest
15min 30min 15min
Results: Energy Expenditure X Exercise
Hickmann C.E. et all Intensive Care Med (2014)40:548-555
Blood lactate was not modified. Blood lactate was A: yes B: notmodified?
• The critically ill have increased REE according to inflammation defined by CRP (C-reactive protein).
• Increased energy requirement for physical activity was only present for active exercise and seems to differ with healthy population.
• For the exercise duration and intensity tested, nutritional adjustment is not indicated (the total amount of consumed calories was limited).
• The impact of prolonged active mobilization should be further investigated.
Conclusions (Hickmann)
Hickmann C.E. et all Intensive Care Med (2014)40:548-555
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Casus
Initialen: DMGeslacht: vrouwLeeftijd: 77 jaarBMI: 17kg/m214-22/8/’17: opname omv respiratoire klachten te Mol23/8/’17: transfer naar UZLEUVEN GasthuisbergAantal ligdagen ITE: 45 Diagnose: mitralisklepplastie ikv endocarditisComplicaties: cardiogene shock, pneumonie
Casus
RELEVANTE MEDISCHE VOORGESCHIEDENIS:
- diabetes mellitus- alzheimer dementie- osteoporose- cachexie- sarcopenia?
Casus
Alfonso J. Cruz-Jentoft et all,Age Ageing. 2010 Jul; 39(4): 412–423.
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Casus
VALLEN:
- Aantal valincidenten afgelopen 12 maanden: 0- Gekende valproblematiek: Neen- Valangst: een beetje- Veilig schoeisel: neen (open schoeisel met hak)- Duizeligheid of draaierigheid: neen
Casus
ACTIVITEITEN VAN HET DAGELIJKS LEVEN: (ADL,KATZ-schaal)
* Wassen en kleden volledige hulp nodig*Transfer en verplaatsen: volledig zelfstandig, zonderloophulpmiddel (rollator die ze wel heeft)
* Toiletbezoek (verplaatsen, kleden, reinigen): zelfstandig* Continentie: continent* Eten: zelfstandig
Casus
BESLUIT:
Op basis van het geriatrisch assessment werden volgende geriatrische noden bij de patiënt bepaald:- Risico op functionele achteruitgang
* Ergo-evaluatie: zelfredzaam* Kiné in te schakelen ikv bepalen nood LHM
- Aanwezigheid cognitieve beperking* Pt gekend met Alzheimer* Opvolging te Mol
- Aanwezigheid mogelijks problematische thuissituatie* Sociale dienst in te schakelen
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Casus
HUIDIGE STATUS(07/10/’17):
Neurologisch: wakker, S5Q: 4/5, delier?Hemodynamisch: stabiel, mits pacemaker Nefro: AKI in recuperatieEMG: CIPMP (ICUAW)Tracheotomie op 15/09/2017
Respiratory assessment and training:
• Tracheakap / PSV
• MIP/Pimax• (max.insp.pressure):
45% (normal value)
*Marini J.J., et al. J Crit Care 1986; 1: 32-38
Tapered flow resistive loading(POWERbreathe KH1)
• 4 sets of 6-10 breaths
• 7 days/week
• 30-50%MIP • 4-6 Borg Score – effort
and dyspnea
Inspiratory muscle training:
15cmH20
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Assessment: UZLeuven ‘Start to Move’ ASAP protocol
UZLEUVEN ‘START TO MOVE’ ASAP (from day 2 with an expected prolonged ICU stay of 5 more days)
LEVEL 0
VARIABLE COOP.S5Q1 = 0-5
NO COOPERATIONS5Q1 = 0-5
VARIABLE COOP.S5Q1 = 0-5
CLOSE-FULL COOP.S5Q1 ≥ 4/5
FULL COOP.S5Q1 = 5
FULL COOP.S5Q1 = 5
LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5
FAILS BASIC ASSESSMENT2
PASSES BASIC ASSESSMENT3
PASSES BASIC ASSESSMENT3
PASSES BASIC ASSESSMENT3
PASSES BASIC ASSESSMENT3
PASSES BASIC ASSESSMENT3
TRANSFER to chairnot allowed becauseof neurological orsurgical or trauma condition
ACTIVE TRANSFER to chair not allowedbecause of obesityor neurological orsurgical or trauma condition
MRCsum ≥ 36(MRCsumLL≥ 18)BBS Sit to stand = 0BBS Standing = 0BBS Sitting ≥ 1
MRCsum ≥ 48(MRCsumLL≥ 24)BBS Sit to stand ≥ 0BBS Standing ≥ 0BBS Sitting ≥ 2
MRCsum ≥ 48BBS Sit to stand ≥ 1BBS Standing ≥ 2BBS Sitting ≥ 3
BODY POSITIONING4
°2h turning°Splinting°Positioning
BODY POSIT.4
°2h turning°Splinting°Upright sittingposition in bed
°Passive transfer bed to chair
BODY POSIT.4
°2h turning°Passive transfer bed to chair
°Sitting out of bed°Standing withassist (≥ 2 pers)
BODY POSIT.4
°2h turning°Splinting°Fowler’s position
BODY POSIT.4
°Active transfer bed to chair
°Sitting out of bed°Standing withassist (≥ 1 pers)
BODY POSIT.4
°Active transfer bed to chair
°Sitting out of bed°Standing
PHYSIOTHERAPY°No treatment
PHYSIOTHER.4
°Passive/active ROM°Passive/active leg and/or arm cyclingin bed°NMES°ADL
PHYSIOTHER.4
°Passive/active ROM°Resistance training arms and legs
°Passive/active leg and/or arm cyclingin bed or chair
°NMES°ADL
PHYSIOTHER.4
°Passive/active ROM°Resistance training arms and legs
°Active leg and/orarm cycling in bed or chair
°Standing (withassistance/frame) °NMES°ADL
PHYSIOTHER.4
°Passive/active ROM°Resistance training arms and legs
°Active leg and/orarm cycling in bedor chair
°Walking (withassistance/frame)
°NMES°ADL
CLINICAL IN
VESTIGATION
REH
ABILITATION
INTENSIEVE GENEESKUNDE
MULITD
ISCIPLINARY APPROACH
PHYSIOTHER.4
°Passive/active ROM°Resistance training arms and legs
°Active leg and/orarm cycling in bedor chair
°Walking (withassistance)
°NMES°ADL
ADEQUACY SCOREA. Open and close your eyesB. Look at meC. Open your mouth and put out your tongueD. Nod your headE. Raise your eyebrows when I have counted
up to five
BERG BALANCE SCORESITTING TO STANDING4 able to stand without using hands and
stabilize independently3 able to stand independtly using hands2 able to stand using hands after several tries1 needs minimal aid to stand or stabilize0 needs moderate or maximal assist to stand
Right Reason EP Left Reason EP
MS: Abduction of the arm
MS: Flexion of the forearm
MS: Extension of the wrist
MS: Flexion of the leg
MS: Extension of the knee
MS: Dorsal flexion of the foot
STRENGTH SUBTOTAL VALUE STRENGTH TOTAL=
EP SUBTOTAL VALUE EP TOTAL =
MRC TOTAL SUMSCORE
MRC-SCALE0 = no visible contraction1 = visible contraction without movements of the limbs2 = movements of the limbs but not against gravity3 = movement against gravity over (almost) the full range4 = movement against gravity and resistance5 = normal
MRC-SUMSCORE Pre-existing NMD: □ No □ Yes:______________
Dominantie:
STANDING UNSUPPORTED4 able to stand safely for 2 minutes3 able to stand 2 minutes with supervision2 able to stand 30 secondes unsupported1 needs several tries to stand 30 secondes
unsupported0 unable to stand 30 secondes unsupported
SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL4 able to sit safely and securely for 2 minutes3 able to sit 2 minutes under supervision2 able to sit 30 seconds1 able to sit 10 seconds0 unable to sit 10 seconds unsupported
1: score 5 questions: adequate response to 5 standardized orders
2: FAILS = at least 1 risk factor present3: if basic assessment failed, decrease to level 04: safety and feasibility: each activity should be
deferred if severe adverse events (cv., resp., internal and subject. intolerance) occur duringthe intervention
BASIC ASSESSMENT =-Cardiorespiratory unstable
* MAP < 60mmHg or* FiO2 > 60% or* PaO2/Fi02 < 200 or* RR > 30 bpm
-Neurologically unstable-Acute surgery-Temp > 40°C
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SCORE 5 QUESTIONS2
A. Open and close your eyes □
B. Look at me □
C. Open your mouth and put out your tongue □
D. Nod your head □
E. Raise your eyebrows when I have counted up to five □
De Jonghe B., et al. Crit Care Med 2007; 35(9): 2007-14.
Adequacy score
‐ Cardiorespiratory unstable* MAP < 60mmHg or* FiO2 > 60% or* PaO2/Fi02 < 200 or* RR > 30 bpm
‐ Neurologically unstable
‐ Acute surgery
‐ Temp > 40°C
Basic assessment
0 = No visible contraction
1 = Visible contraction without movements of the limbs
2 = Movements of the limbs but not against the gravity
3 = Movement against gravity over (almost) the full range
4 = Movement against gravity and resistance
5 = Normal
Kleyweg R.P., et al. Muscle Nerve 1991; 14(II): 1003‐09.
MRC‐scale: 0‐5 score
Functional assessment
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Score < 48/60:‘significantmuscle weakness’
De Jonghe B, JAMA 2002
MRC total sumscore: 38/60
Berg Balance score ‘Start to move asap’ protocolBerg Balance score
SITTING TO STANDING4 able to stand without using hands and stabilize independently3 able to stand independently using hands2 able to stand using hands after several tries1 needs minimal aid to stand or stabilize0 needs moderate or maximal assist to stand
STANDING UNSUPPORTED4 able to stand safely for 2 minutes3 able to stand 2 minutes with supervision2 able to stand 30 seconds unsupported1 needs several tries to stand 30 seconds unsupported0 unable to stand 30 seconds unsupported
SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL4 able to sit safely and securely for 2 minutes3 able to sit 2 minutes under supervision2 able to able to sit 30 seconds1 able to sit 10 seconds0 unable to sit without support 10 seconds
Handgrip force (JAMAR®)
Handheld dynamometry, handgrip strength:
Isometric muscle testing (MicroFet®)
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Handgrip force (JAMAR®)
handgrip strength: 25% (normal value)
Enteral feeding: (swallowing disorder)
LEVEL 0 LEVEL 5LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4
UZLEUVEN ‘START TO MOVE' ASAP
CLOSE TO FULLCOOPERATION
S5Q1 ≥ 4/5
PASSES BASIC ASSESSMENT3 +
MRCsum ≥ 36 +
BBS² Sit to stand = 0 +
BBS² Standing = 0 +
BBS² Sitting ≥ 1
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BODY POSITIONING
2hr turning
Passive transfer bed to chair
Sitting out of bed
Standing with assist (2 ≥ pers)
Jointly with nursing staff
LEVEL 0 LEVEL 5LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4
UZLEUVEN ‘START TO MOVE' ASAP
CLOSE TO FULLCOOPERATION
S5Q1 ≥ 4/5
PASSES BASIC ASSESSMENT3 +
MRCsum ≥ 36 +
BBS² Sit to stand = 0 +
BBS² Standing = 0 +
BBS² Sitting ≥ 1
BODY POSITIONING4
2hr turning
Passive transfer bed to chair
Sitting out of bed
Standing with assist (2 ≥ pers)
PHYSIOTHERAPY:
Passive/Active range of motion
Resistance training arms and legs
Active leg and/or arm cycling in chairor bed
Walking (with assistance/frame)
NMES
ADL
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NMES:
PHYSIO in combination FEEDING
Walking > adjustment Insuline (discontinuation feeding)
ADL > functional > eating, drinking
Logopedy > swallowing disorders for eating
LEVEL 0 LEVEL 5LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4
UZLEUVEN ‘START TO MOVE' ASAP
CLOSE TO FULLCOOPERATION
S5Q1 ≥ 4/5
PASSES BASIC ASSESSMENT3 +
MRCsum ≥ 36 +
BBS² Sit to stand = 0 +
BBS² Standing = 0 +
BBS² Sitting ≥ 1
BODY POSITIONING4
2hr turning
Passive transfer bed to chair
Sitting out of bed
Standing with assist (2 ≥ pers)
PHYSIOTHERAPY4
Passive/Active range of motion
Resistance training arms and legs
Active leg and/or arm cycling in bed or chair
NMES
ADL
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Conclusions I
Critical Illness is associated with short and long term morbidity (functional status, quality of life)
There is a variety of exercise modalities available for early stages of critical illness that facilitate functional
outcome
Conclusions II
The role of physiotherapy and rehabilitation in early prevention and treatment of deconditioning during and
after critical illness need much more attention
Research should be conducted to further establish the effectiveness of exercise modalities in patients with critical illness on muscle function, QOL and physical
function
Conclusions III
Treatment should be administered jointly between medical, physical therapy and
nursing staff.
The physical therapist should be responsible for implementing mobilization plans and exercise prescription and make
recommendations for progression of these in conjunction with other team
members.