ICU-Acquired weakness: Implications for PT

managementPresented By: Chris Grant SPTA

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

MRC table

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)

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.

Criteria for starting Physical Therapy

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.

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

PFIT

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

techniques

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)

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

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.

How much Do we challenge Patients??

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

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.

Questions

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Thank you