rehabilitation for patients with critical illness: current ... · ciesla n, dinglas v, fan e, kho...

KPTA Eastern District Meeting

Rehabilitation for patients with critical illness: Current and future directions

Kirby Mayer, DPT

Graduate Research Assistant

A c k n o w l e d g e m e n t s

THANK YOUAngie Henning, DPT

A c k n o w l e d g e m e n t s No financial disclosures

Part of this presentation was presented at ACRM National Conference in 2017

A g e n d a

• Background

• Landmark

Manuscripts

• ICU Rehab

• Early Mobility

• Interventions

• Future Directions

L e a r n i n g O b j e c t i v e s

• To understand the risks associated with critical illness and burden of survivorship

• To describe a framework for selection of interventions for patients with critical illness

• To synthesize ICU rehabilitation interventions and importance of continued rehab during recovery

B a c k g r o u n d

• 6-9 million survivors of critical illness annually

• Individual and family consequences

• Societal and healthcare burden

http://www.icudelirium.org/testimonials.html

S u r v i v o r s h i pICU-acquired weakness:“Clinically detectable global and symmetrical muscle wasting and weakness with no plausible etiology other than critical illness”

Multiple organ

failure > 2

Immobility

Severe infection

(SIRS)

Blood Glucose

levelsProlonged Ventilation

Prolonged ICU stay > 1

week

Inflammation

Medication(sedation, steroids)

S u r v i v o r s h i p

Puthucheary et al JAMA 2013 Parry et al J Crit Care 2015


Post Intensive Care syndrome

(PICS)

Survivor (PICS)

Mental Health Cognitive Impairments

Family(PICS)

Mental HealthPhysicalImpairments

Needham et al 2011 CCM


3 mos. 6 mos. 1 year 3 years 5 yearsN= 80 N=78 N=81 N=71 N=54

6 MWT (m) 281 m 396 m 422 m 418 m 436 m% Predicted 49% 64% 66% 67% 76%

Return to work 3 mos 6 mos 1 yr 3 yrs 5 yrsNo./ total

(%)13/83 (16%)

26/82 (32%)

40/82 (49%)

50/71(70%)

55/71(77%)


http://www.youtube.com/watch?v=30sbefBcjEU&feature=youtu.be

http://www.cbsnews.com/news/study-icu-stays-lead-to-alzheimers-like-problems-in-one-third-of-patients/

http://www.youtube.com/watch?v=30sbefBcjEU&feature=youtu.be

http://www.cbsnews.com/news/study-icu-stays-lead-to-alzheimers-like-problems-in-one-third-of-patients/


Survivorship will be the defining challenge of critical care in the

21st century Iwashyna 2010


What is the role of the Physical Therapist

during critical illness???

I C U Re h a b i l i t a t i o n

1899 Dr. Reis published in JAMA

“period for which it was advisable to confine such cases to bed could be counted by hours instead of days, so that of late I have allowed my patients to get up within 24 to 48 hours. I could not fail to notice these same patients did not present with the same picture of listlessness and muscular weakness”

Reis E. Some Radical Changes in the After-Treatment of Celiotomy Cases. JAMA. 1899; 33: 454- 6.

I C U Re h a b i l i t a t i o n1947 Dr. AJ Asher published in British Medical Journal

“Dangers of Going to Bed”

“complication of rest may cause considerable crippling…weakness and wasting of the general skeletal musculature”

“calcium drains from the bones, disuse osteoporosis can be a serious matter”

“the demoralizing effects of staying in bed…may produce fussiness, pettiness, and irritability.”


1972 in PTJ by Foss

“A method for augmenting ventilation during ambulation”

“early ambulation has been well documented in our ICU by improved sense of well-being and the increased strength the patient develops”


1975 in CHEST by Dr. Burn and Dr. Jones

“Early ambulation of patients requiring ventilatory assistance”

I C U Re h a b i l i t a t i o n1998 in CHEST by Dr. Petty

“Suspended Life or Extending Death”

“what I see these days are sedated patients, lying without motion, appearing to be dead, except for the monitors that tell me otherwise.”

“in 1964, patients who required mechanical ventilation were awake and alert…by being awake and alert, these individuals could interact with their family, friends, and the environment.”


Early Mobility is NOT a new idea!


Early Mobility


ICU Rehabilitation is NOT early mobility

Early mobility IS one component of ICU rehabilitation


Interventions when early mobility is contraindicated orpatient is physical not ready to mobilize

• Passive ROM• Massage• Supine Cycle• NMES and FES• Tilting• Standing frame• Ther-Ex

Unable to actively participate

Active engagement

I C U Re h a b i l i t a t i o nDetermining point of awakening and presence of delirium• Riker SAS/RASS

• CAM ICU (Delirium)

• De Jonghe (5 commands)• Open (close) eyes• Nod head• Look at me• Open mouth and poke

out tongue• Raise eyebrows when

count to five


Supine Cycle

• EMS can be applied early

• Optimal stimulation parameters yet to be determined

• Need larger RCTs with follow up to determine efficacy

I C U Re h a b i l i t a t i o nTilting

• Early weight-bearing• Reduce the time gap between

immobility and early mobility

Purported to improve:• Pulmonary function• Regulate BP• Arousal• GI motility• Stimulate musculoskeletal


Multiple Avenues for early weight-bearing/tilting: tilt table, total lift beds, Sara combilizer, Moveoplatform, Erigo

I C U Re h a b i l i t a t i o nMassage

• Massage (cyclic compressive loading): potential anabolic intervention on atrophied muscle

• Rat immobilization model (hind-limb unloading)

• Muscle fiber CSA enhanced by 18% in massage during period of regrowth compared to reloading alone

• Muscle fiber CSA increased by 17% in contralateral (non-massaged limb

I C U Re h a b i l i t a t i o nMassage also purported:

o To reduce paino To reduce anxietyo To promote relaxation and help with sleep patternso To regulate the immunomodulatory responseo To mitigate cellular stress

• Reducing inflammation• Promoting mitochondrial biogenesis


Results• Improved ventilator-free days• Improved ICU and hospital LOS• Improved QOL, function, peripheral and

respiratory muscle strength• Leg strength improvements correlated

with ambulatory ability• No difference in mortality risk


• Exercise and early PT = only effective intervention to improve long-term physical function in critically ill


~ 900 admissions with LOS reductions of 22% for the ICU and 19% for floor =

$817,836

Po s t - I C U Re h a b i l i t a t i o n

Be Creative, Be Engaging, and Advocate!

F u t u r e D i r e c t i o n s

Multi-Center RCT: eStimCycle


Addressing RCT with “negative” results


Despite benefits of early rehabilitation:


ICU Rehabilitation is NOT new

ICU Rehabilitation is NOT early mobility

Early mobility IS a component of ICU rehabilitation

Something is Better than Nothing

Utilize technology, resources, and advocate!

Re f e r e n c e s1. SM, El-Ansary D, Cartwright MS, Sarwal A, Berney S, Koopman R, Annoni R, Puthucheary Z, Gordon IR, Morris PE et al:

UltrasonHerridge MS, Cheung AM, Tansey CM, Matte-Martyn A, Diaz-Granados N, Al-Saidi F, Cooper AB, Guest CB, Mazer CD, Mehta S et al: One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med 2003, 348(8):683-693.

2. Herridge MS, Tansey CM, Matte A, Tomlinson G, Diaz-Granados N, Cooper A, Guest CB, Mazer CD, Mehta S, Stewart TE et al: Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011, 364(14):1293-1304.

3. Hill AD, Fowler RA, Pinto R, Herridge MS, Cuthbertson BH, Scales DC: Long-term outcomes and healthcare utilization following critical illness--a population-based study. Crit Care 2016, 20:76.

4. Hopkins RO, Weaver LK, Collingridge D, Parkinson RB, Chan KJ, Orme JF, Jr.: Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome. Am J Respir Crit Care Med 2005, 171(4):340-347.

5. Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT, Brummel NE, Hughes CG, Vasilevskis EE, Shintani AK et al: Long-term cognitive impairment after critical illness. N Engl J Med 2013, 369(14):1306-1316.

6. Bienvenu OJ, Colantuoni E, Mendez-Tellez PA, Shanholtz C, Dennison-Himmelfarb CR, Pronovost PJ, Needham DM: Cooccurrence of and remission from general anxiety, depression, and posttraumatic stress disorder symptoms after acute lung injury: a 2-year longitudinal study. Crit Care Med 2015, 43(3):642-653.

7. Hermans G, Van Mechelen H, Clerckx B, Vanhullebusch T, Mesotten D, Wilmer A, Casaer MP, Meersseman P, Debaveye Y, Van Cromphaut S et al: Acute outcomes and 1-year mortality of intensive care unit-acquired weakness. A cohort study and propensity-matched analysis. Am J Respir Crit Care Med 2014, 190(4):410-420.

8. Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Phadke R, Dew T, Sidhu PS et al: Acute skeletal muscle wasting in critical illness. JAMA 2013, 310(15):1591-1600.

9. Parry ography in the intensive care setting can be used to detect changes in the quality and quantity of muscle and is related to muscle strength and function. J Crit Care 2015, 30(5):1151 e1159-1114.

10. Ciesla N, Dinglas V, Fan E, Kho M, Kuramoto J, Needham D: Manual muscle testing: a method of measuring extremity muscle strength applied to critically ill patients. J Vis Exp 2011(50).

11. Adler J, Malone D: Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J 2012, 23(1):5-13. 12. Li Z, Peng X, Zhu B, Zhang Y, Xi X: Active mobilization for mechanically ventilated patients: a systematic review. Arch Phys Med

Rehabil 2013, 94(3):551-561.

13. Kayambu G, Boots R, Paratz J: Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med 2013, 41(6):1543-1554 14. Calvo-Ayala E, Khan BA, Farber MO, Ely EW, Boustani MA: Interventions to improve the physical function of ICU survivors: a systematic review. Chest 2013, 144(5):1469-1480. 15. Connolly B, O'Neill B, Salisbury L, Blackwood B, Enhanced Recovery After Critical Illness Programme G: Physical rehabilitation interventions for adult patients during critical illness: an overview of systematic reviews. Thorax 2016, 71(10):881-890.

16. Burtin C, Clerckx B, Robbeets C, Ferdinande P, Langer D, Troosters T, Hermans G, Decramer M, Gosselink R: Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med 2009, 37(9):2499-2505.17. Kho ME, Molloy AJ, Clarke FJ, Ajami D, McCaughan M, Obrovac K, Murphy C, Camposilvan L, Herridge MS, Koo KK et al: TryCYCLE: A Prospective Study of the Safety and Feasibility of Early In-Bed Cycling in Mechanically Ventilated Patients. PLoS One 2016, 11(12):e0167561.18. Parry SM, Berney S, Warrillow S, El-Ansary D, Bryant AL, Hart N, Puthucheary Z, Koopman R, Denehy L: Functional electrical stimulation with cycling in the critically ill: a pilot case-matched control study. J Crit Care 2014, 29(4):695 e691-697.19. Parry SM, Berney S, Granger CL, Koopman R, El-Ansary D, Denehy L: Electrical muscle stimulation in the intensive care setting: a systematic review. Crit Care Med 2013, 41(10):2406-2418.20. Parry SM, Berney S, Koopman R, Bryant A, El-Ansary D, Puthucheary Z, Hart N, Warrillow S, Denehy L: Early rehabilitation in critical

care (eRiCC): functional electrical stimulation with cycling protocol for a randomised controlled trial. BMJ Open 2012, 2(5).21. Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, Ross A, Anderson L, Baker S, Sanchez M et al: Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008, 36(8):2238-2243.22. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D et al: Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009, 373(9678):1874-1882.23. Denehy L, Skinner EH, Edbrooke L, Haines K, Warrillow S, Hawthorne G, Gough K, Hoorn SV, Morris ME, Berney S: Exercise rehabilitation for patients with critical illness: a randomized controlled trial with 12 months of follow-up. Crit Care 2013, 17(4):R156.24. Puthucheary ZA, Denehy L: Exercise Interventions in Critical Illness Survivors: Understanding Inclusion and Stratification Criteria. Am J Respir Crit Care Med 2015, 191(12):1464-1467.25. Morris PE, Berry MJ, Files DC, Thompson JC, Hauser J, Flores L, Dhar S, Chmelo E, Lovato J, Case LD et al: Standardized Rehabilitation and Hospital Length of Stay Among Patients With Acute Respiratory Failure: A Randomized Clinical Trial. JAMA 2016, 315(24):2694-2702.26. Moss M, Nordon-Craft A, Malone D, Van Pelt D, Frankel SK, Warner ML, Kriekels W, McNulty M, Fairclough DL, Schenkman M: A Randomized Trial of an Intensive Physical Therapy Program for Patients with Acute Respiratory Failure. Am J Respir Crit Care Med 2016, 193(10):1101-1110.

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