Rehabilitation in the ICU: More Questions Than Answers
December 1, 2016 6 minutes read
By Kathryn Radigan, MD
Attending Physician, Division of Pulmonary and Critical Care, Stroger Hospital of Cook County, Chicago
Dr. Radigan reports no financial relationships relevant to this field of study.
SYNOPSIS: In patients with acute respiratory failure, standardized rehabilitation therapy consisting of passive range of motion, physical therapy, and progressive resistance exercise did not decrease hospital length of stay compared to usual care.
SOURCE: Morris PE, Berry MJ, Files DC, et al. Standardized rehabilitation and hospital length of stay among patients with acute respiratory failure: A randomized clinical trial. JAMA 2016;28;315:2694-2702.
Patients who survive acute respiratory failure often endure impaired physical function for years after their critical illness. Physical therapy in the ICU may improve the outcomes of patients with acute respiratory failure. To evaluate the benefits of physical therapy, Morris et al conducted a single-center, randomized clinical trial at Wake Forest Baptist Medical Center in North Carolina. From October 2009 through May 2014, adult patients who were admitted to the ICU with acute respiratory failure requiring mechanical ventilation (PaO2/FiO2 < 300) were randomized to standardized rehabilitation therapy (SRT) or usual care and followed for six months. Exclusion criteria included inability to walk without assistance prior to ICU admission, cognitive impairment prior to admission to ICU, body mass index > 50 kg/m2, neuromuscular disease that may impair ventilator weaning, acute hip fracture/unstable cervical spine fracture, mechanical ventilation > 80 hours or existing hospitalization > 7 days, patients with do-not-intubate (DNI) orders, or moribund state. For the duration of their admission to the hospital, SRT patients received daily therapy, including passive range of motion, physical therapy, and progressive resistance exercise. Usual care patients received weekday physical therapy when ordered by the clinical team. If the patient was unconscious, the sessions consisted of passive range of motion. The median days of delivery of therapy for the SRT group was 8.0 (IQR 5.0-14.0) for passive range of motion, 5.0 (IQR 3.0-8.0) for physical therapy, and 3.0 (IQR 1.0-5.0) for progressive resistance exercise. For the usual care group, the median days of physical therapy was 1.0 (IQR 0.0-8.0). Patients underwent blinded assessment at ICU discharge, at hospital discharge, and at two, four, and six months. The primary outcome was hospital length of stay (LOS) with secondary outcomes including ventilator days, ICU days, Short Physical Performance Battery (SPPB) score, Functional Performance Inventory (FPI) score, Mini-Mental State Examination (MMSE) score, handgrip and handheld dynamometer strength, 36-item Short-Form Healthy Surveys (SF-36) for physical and mental health, and physical function scale score.
Three hundred patients were randomized with no difference in median hospital LOS between the SRT group (median 10 days, IQR 6-17) and usual care group (median 10 days, IQR 7-16; median difference 0; 95% confidence interval [CI], -1.5 to 3; P = 0.41). There also was no difference in duration of mechanical ventilation or ICU care and no effect at six months for handgrip (difference, 2.0 kg; 95% CI, -1.3 to 5.4; P = 0.23) and handheld dynamometer strength (difference, 0.4 lb; 95% CI, -2.9 to 3.7; P = 0.82), SF-36 physical health score (difference, 2.4; 95% CI, -1.2 to 6.0; P = 0.19), and MMSE score (difference, 0.6; 95% CI, -0.2 to 1.4; P = 0.17). At six months, the SRT group scored higher on the SPPB (difference, 1.1; 95% CI, 0.04-2.1; P = 0.04), SF-36 physical function scale (difference, 12.2; 95% CI, 3.8-20.7; P = 0.001), and the FPI (difference, 0.2; 95% CI, 0.04-0.4; P = 0.02). In summary, SRT consisting of passive range of motion, physical therapy, and progressive resistance exercise did not decrease hospital length of stay compared to usual care.
COMMENTARY
Approximately 50% of critically ill patients with sepsis, multi-organ failure, or prolonged respiratory failure exhibit protracted muscular weakness that often persists after hospital discharge.1 Within the last decade, the practice of placing critically ill patients on bed rest, often in a medication-induced coma, has been transformed to seeing mechanically ventilated patients ambulating around the ICU, all in an attempt to transform long-term outcomes in this patient population. A number of studies have addressed both the benefits and safety of physical therapy in the ICU. However, these same studies have raised questions about the timing, quantity, and type of rehabilitation that would be most beneficial for specific groups of ICU patients. To further investigate the benefits of rehabilitation in the ICU setting, Morris et al conducted a randomized, clinical trial comparing early daily delivery of a structured, multifaceted ICU and hospital rehabilitation program to usual care. Unfortunately, the researchers found there were no differences in hospital length of stay, ventilator-free days, or ICU-free days. Furthermore, functional-related and health-related quality of life outcomes were similar for both the SRT and usual care groups at discharge.
Despite no differences in outcomes between the two groups, there was substantially more exercise delivered and performed in the SRT group vs. the usual care group. The usual care group received physical therapy for only 12% of the study days while the SRT group received passive range of motion for 87% of the study days, physical therapy for 55% of the study days, and progressive resistance exercise for 36% of the study days. Although the benefit of this therapy was not obvious at hospital discharge, there were differences in physical function measures (SPPB, SF-36 PFS, and FPI) at six months. Perhaps, outcomes of critically ill patients who undergo physical rehabilitation in the ICU should be measured at six months or even one year after their critical illness. Of course, following patients for longer periods of time would have to be tempered by the possibility of higher dropout rates, which already were higher than expected for this study, with 24% lost to follow-up or withdrawals.
Unfortunately, a significant limitation of this study was the lack of a standardized sedation protocol. Within the intervention group, 30% of the patients’ ventilator days were associated with continuous drip medications, and for 15% of the ventilator days, the patients were unarousable. It has been well described how difficult it is to institute a successful mobility program without a significant change in culture, including an aggressive sedation protocol addressing treatment of delirium and limitation of sedative medications. Although a culture change may be initiated in a variety of ways, the ABCDE Initiative has been successful and outlines straightforward tenants to be aggressive and successful with this culture change. The ABCDE bundle includes implementing the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility (ABCDE) bundle on a daily basis.2 Compared to a control group, patients who underwent the ABCDE bundle spend more days breathing without mechanical ventilation, experience less delirium, and increase their odds of mobilizing out of bed at least daily compared to pre-bundle patients. It remains a concern that the patients in the Morris et al study underwent no sedation protocol. A different trial by Schweikert et al highlighted this concern as they were able to show that interruption of sedation along with physical and occupational rehabilitation is most important during mechanical ventilation, specifically within a median of 1.5 days after intubation.3 Despite the same amount of daily physical therapy after mechanical ventilation, the intervention group received an average of 19 minutes of physical therapy per day during mechanical ventilation while the control group received no physical therapy until after extubation. Although the Morris et al study does not reveal at what time point the patients received physical therapy, it appears there was a delay that was more than ideal, with patients receiving physical therapy on average five days into their 10-day hospital stay.
Although the exact prescription of rehabilitation and the best time to measure outcomes may still be in question, it makes sense that patients would benefit from physical therapy in the ICU setting. This study was helpful in highlighting the need for culture change in our ICUs with an aggressive sedation protocol. It also highlighted the benefit of measuring longer-term outcomes in our patients. However, this study also should challenge us to continue to ask questions, namely, which critically ill patient should receive what type of rehabilitation at what stage in his or her illness and for what period of time?
REFERENCES
- Stevens RD, Dowdy DW, Michaels RK, et al. Neuromuscular dysfunction acquired in critical illness: A systematic review. Intensive Care Med 2007;33:1876-1891.
- Balas MC, Vasilevskis EE, Olsen KM, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med 2014;42:1024-1036.
- Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. Lancet 2009;373:1874-1882.
In patients with acute respiratory failure, standardized rehabilitation therapy consisting of passive range of motion, physical therapy, and progressive resistance exercise did not decrease hospital length of stay compared to usual care.
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