Early rehabilitation in the ICU: MOVE IT or LOSE IT = ICUAW

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1 Early rehabilitation in the ICU: MOVE IT or LOSE IT Beatrix Clerckx, PT Department of Rehabilitation Sciences, Department of Intensive Care Medicine, University Hospitals Leuven, KU Leuven Belgium (Pathophysiological mechanisms) = ICUAW Truong Crit.Care 2009;13(4):216 Weaning failure Emotional functioning Deconditioning, Inactivity +++ Sarcopenia: Low muscle mass, muscle strength, physical performance 1

ICUAW and clinical outcome Cumulative proportion weaned alive from

DISCHARGE ICU DISCHARGE HOSPITAL Cumulative proportion discharged

AJRCCM 2014 ICUAW and survival Hermans et al.

2 ICUAW and clinical outcome Cumulative proportion weaned alive from MV Cumulative proportion discharged alive from ICU WEANING DISCHARGE ICU DISCHARGE HOSPITAL Cumulative proportion discharged alive from hospital Hermans et al. AJRCCM 2014 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

3 CHEST/144/3/SEPTEMBER 2013 Reck MOTOmed Movement Therapy Systems, Germany Studie design Critically ill patient 5 days ICU and forecast of another 7 days at the ICU Cycle programme (passive/active) 20 per day in addition to Usual care Usual care: respiratory physiotherapy mobilisation Burtin et al. CCM 2009; 37:

3.0 p < 0.01 p < 0.05 p < 0.05 600 2.5 500 QF (N/kg) 2.0 1.5 6MWD (m) 400 300 200 100 1.

05 25 20 15 10 0 TR CO 196 [126-329] m 143 [37-226] m In general, the achieved absolute workload during cycling

TR CO 21 [18-23] points 15 [14-23] points Burtin C, CCM 2009 The feasibility and safety of early physical therapy in

4 3.0 p < 0.01 p < 0.05 p < QF (N/kg) MWD (m) TR CO TR CO ICU discharge hospital discharge SF-36 PF score (10-30) 30 p < TR CO 196 [ ] m 143 [37-226] m In general, the achieved absolute workload during cycling exercise was?: very low A: very and low HR, blood pressure, and B: very high respiratory rate did not change. TR CO 21 [18-23] points 15 [14-23] points Burtin C, CCM 2009 The feasibility and safety of early physical therapy in ICU patients Frequently researched in highly specialized (university) centers Nevertheless there are still perceived barriers to facilitate rehabilitation on the ICU Bourdin et al. Respir. Care 2010: 55:400 4

Passive / active cycling Is het mogelijk om met een gesedeerde

A: Ja B: Nee Solutions for barriers Other material ( Be

protocols UZ LEUVEN Start to move asap protocol Last decade >

5 Passive / active cycling Is het mogelijk om met een gesedeerde patiënt te fietsen? A: Ja B: Nee Solutions for barriers Other material ( Be creative ) Team Work Change in mentality (worldwide) Mobility protocols UZ LEUVEN Start to move asap protocol Last decade > development of different mobility protocols (Morris et al. 2008, Schweickert et al. 2009) UZ LEUVEN start to move ASAP protocol (+/-2009) > The proposition of the protocol is discussed, adapted and evaluated by multidisciplinary team members 5

6-level program deliver daily mobility or physical activity from day 2 after admission to the ICU each level is determined by assessment using objective measurements each level consists of a variety

6 6-level program deliver daily mobility or physical activity from day 2 after admission to the ICU each level is determined by assessment using objective measurements each level consists of a variety of body positions and modalities for physical training and early mobility Is feeding another barrier? What about underfeeding or overfeeding having deliterious consequences for critically ill patients? How can we optimize objectively the benefits of exercise efforts in ICU- critical ill patients? Are combined, nutrition and exercise interventions, potential strategies to prevent or attenuate ICUAW and associated functional impairments? 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:

Methods prospective observational study - 49 hemodynamically stable critically ill patients - 15 healthy volunteers Indirect Calorimetry (V02, VC02) Rest Exercise at 0,3 or 6 Watt Rest 15min 30min

Increased energy requirement for physical activity was only present for active exercise and seems to differ with healthy population.

7 Methods prospective observational study - 49 hemodynamically stable critically ill patients - 15 healthy volunteers Indirect Calorimetry (V02, VC02) Rest Exercise at 0,3 or 6 Watt Rest 15min 30min 15min Hickmann C.E. et all Intensive Care Med (2014)40: Results: Energy Expenditure X Exercise Blood Blood lactate lactate was was not modified. A: yes B: not modified? Hickmann C.E. et all Intensive Care Med (2014)40: Conclusions (Hickmann) 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. Hickmann C.E. et all Intensive Care Med (2014)40:

Casus Casus Initialen: DM Geslacht: vrouw Leeftijd: 77 jaar BMI: 17kg/m2 14-22/8/ 17: opname omv respiratoire klachten te Mol 23/8/ 17: transfer naar UZLEUVEN Gasthuisberg Aantal ligdagen ITE: 45

8 Casus Casus Initialen: DM Geslacht: vrouw Leeftijd: 77 jaar BMI: 17kg/m /8/ 17: opname omv respiratoire klachten te Mol 23/8/ 17: transfer naar UZLEUVEN Gasthuisberg Aantal ligdagen ITE: 45 Diagnose: mitralisklepplastie ikv endocarditis Complicaties: cardiogene shock, pneumonie Casus RELEVANTE MEDISCHE VOORGESCHIEDENIS: - diabetes mellitus - alzheimer dementie - osteoporose - cachexie - sarcopenia? Alfonso J. Cruz-Jentoft et all,age Ageing Jul; 39(4):

9 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, zonder loophulpmiddel (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 9

assessment and training: Tracheakap / PSV MIP/Pimax (max.insp.pressure): 45% (normal value) *Marini J.J., et al.

10 Casus HUIDIGE STATUS(07/10/ 17): Neurologisch: wakker, S5Q: 4/5, delier? Hemodynamisch: stabiel, mits pacemaker Nefro: AKI in recuperatie EMG: 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: Inspiratory muscle training: 4 sets of 6-10 breaths 7 days/week 30-50%MIP 4-6 Borg Score effort and dyspnea 15cmH20 Tapered flow resistive loading (POWERbreathe KH1) 10

11 Assessment: UZLeuven Start to Move ASAP protocol REHABILITATION CLINICAL INVESTIGATION UZLEUVEN START TO MOVE ASAP (from day 2 with an expected prolonged ICU stay of 5 more days) LEVEL 0 LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5 NO COOPERATION VARIABLE COOP. VARIABLE COOP. CLOSE-FULL COOP. FULL COOP. FULL COOP. S5Q 1 = 0-5 S5Q 1 = 0-5 S5Q 1 = 0-5 S5Q 1 4/5 S5Q 1 = 5 S5Q 1 = 5 FAILS BASIC PASSES BASIC PASSES BASIC PASSES BASIC PASSES BASIC PASSES BASIC ASSESSMENT 2 ASSESSMENT 3 ASSESSMENT 3 ASSESSMENT 3 ASSESSMENT 3 ASSESSMENT 3 TRANSFER to chair ACTIVE MRCsum 36 MRCsum 48 MRCsum 48 not allowed because TRANSFER to (MRCsum LL 18) (MRCsum LL 24) BBS Sit to stand 1 of neurological or chair not allowed BBS Sit to stand = 0 BBS Sit to stand 0 BBS Standing 2 surgical or trauma because of obesity BBS Standing = 0 BBS Standing 0 BBS Sitting 3 condition or neurological or BBS Sitting 1 BBS Sitting 2 surgical or trauma condition BODY BODY POSIT. 4 BODY POSIT. 4 BODY POSIT. 4 BODY POSIT. 4 BODY POSIT. 4 POSITIONING 4 2h turning 2h turning 2h turning Active transfer Active transfer 2h turning Splinting Splinting Passive transfer bed to chair bed to chair Splinting Fowler s position Upright sitting bed to chair Sitting out of bed Sitting out of bed Positioning position in bed Sitting out of bed Standing with Standing Passive transfer Standing with assist ( 1 pers) bed to chair assist ( 2 pers) PHYSIOTHERAPY PHYSIOTHER. 4 PHYSIOTHER. 4 PHYSIOTHER. 4 PHYSIOTHER. 4 PHYSIOTHER. 4 No treatment Passive/active ROM Passive/active ROM Passive/active ROM Passive/active ROM Passive/active ROM Passive/active leg Resistance training Resistance training Resistance training Resistance training and/or arm cycling arms and legs arms and legs arms and legs arms and legs in bed Passive/active leg Active leg and/or Active leg and/or Active leg and/or NMES and/or arm cycling arm cycling in bed arm cycling in bed arm cycling in bed ADL in bed or chair or chair or chair or chair NMES Standing (with Walking (with Walking (with ADL assistance/frame) assistance/frame) assistance) NMES NMES NMES ADL ADL ADL MULITDISCIPLINARY APPROACH INTENSIEVE GENEESKUNDE 1 : score 5 questions: adequate response to 5 ADEQUACY SCORE BASIC ASSESSMENT = standardized orders A. Open and close your eyes -Cardiorespiratory unstable 2 : FAILS = at least 1 risk factor present B. Look at me * MAP < 60mmHg or 3 : if basic assessment failed, decrease to level 0 C. Open your mouth and put out your tongue * FiO 2 > 60% or 4 : safety and feasibility: each activity should be D. Nod your head * PaO 2/Fi0 2 < 200 or deferred if severe adverse events (cv., resp., E. Raise your eyebrows when I have counted * RR > 30 bpm internal and subject. intolerance) occur during up to five -Neurologically unstable the intervention -Acute surgery -Temp > 40 C BERG BALANCE SCORE STANDING UNSUPPORTED SITTING WITH BACK UNSUPPORTED SITTING TO STANDING 4 able to stand safely for 2 minutes BUT FEET SUPPORTED ON FLOOR OR 4 able to stand without using hands and 3 able to stand 2 minutes with supervision ON A STOOL stabilize independently 2 able to stand 30 secondes unsupported 4 able to sit safely and securely for 2 minutes 3 able to stand independtly using hands 1 needs several tries to stand 30 secondes 3 able to sit 2 minutes under supervision 2 able to stand using hands after several tries unsupported 2 able to sit 30 seconds 1 needs minimal aid to stand or stabilize 0 unable to stand 30 secondes unsupported 1 able to sit 10 seconds 0 needs moderate or maximal assist to stand 0 unable to sit 10 seconds unsupported MRC-SUMSCORE Pre-existing NMD: No Yes: MRC-SCALE 0 = no visible contraction Right Reason EP Left Reason EP 1 = visible contraction without movements of the limbs MS: Abduction of the arm 2 = movements of the limbs but not against gravity MS: Flexion of the forearm 3 = movement against gravity over (almost) the full range MS: Extension of the wrist 4 = movement against gravity and resistance MS: Flexion of the leg 5 = normal MS: Extension of the knee Dominantie: MS: Dorsal flexion of the foot STRENGTH SUBTOTAL VALUE STRENGTH TOTAL= EP SUBTOTAL VALUE EP TOTAL = MRC TOTAL SUMSCORE 11

12 Adequacy score SCORE 5QUESTIONS 2 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): Basic assessment Cardiorespiratory unstable * MAP < 60mmHg or * FiO 2 > 60% or * PaO 2 /Fi0 2 < 200 or * RR > 30 bpm Neurologically unstable Acute surgery Temp > 40 C Functional assessment MRC scale: 0 5 score 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):

MRC total sumscore: 38/60 Score < 48/60: significant muscle weakness De Jonghe B, JAMA 2002 Berg Balance score Start to move asap protocol Berg Balance score SITTING TO

needs minimal aid to stand or stabilize 0 needs moderate or maximal assist to stand STANDING UNSUPPORTED 4 able to stand safely for 2 minutes 3 able to stand 2 minutes

UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL 4 able to sit safely and securely for 2 minutes 3 able to sit 2 minutes under supervision 2 able to able to sit 30

13 MRC total sumscore: 38/60 Score < 48/60: significant muscle weakness De Jonghe B, JAMA 2002 Berg Balance score Start to move asap protocol Berg Balance score SITTING TO STANDING 4 able to stand without using hands and stabilize independently 3 able to stand independently using hands 2 able to stand using hands after several tries 1 needs minimal aid to stand or stabilize 0 needs moderate or maximal assist to stand STANDING UNSUPPORTED 4 able to stand safely for 2 minutes 3 able to stand 2 minutes with supervision 2 able to stand 30 seconds unsupported 1 needs several tries to stand 30 seconds unsupported 0 unable to stand 30 seconds unsupported SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL 4 able to sit safely and securely for 2 minutes 3 able to sit 2 minutes under supervision 2 able to able to sit 30 seconds 1 able to sit 10 seconds 0 unable to sit without support 10 seconds Handheld dynamometry, handgrip strength: Isometric muscle testing (MicroFet ) Handgrip force (JAMAR ) 13

LEVEL 3 LEVEL 4 LEVEL 5 CLOSE TO FULL COOPERATION S5Q 1 4/5 PASSES BASIC

14 handgrip strength: 25% (normal value) Handgrip force (JAMAR ) Enteral feeding: (swallowing disorder) UZLEUVEN START TO MOVE' ASAP LEVEL 0 LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5 CLOSE TO FULL COOPERATION S5Q 1 4/5 PASSES BASIC ASSESSMENT 3 + MRCsum 36 + BBS² Sit to stand = 0 + BBS² Standing = 0 + BBS² Sitting 1 14

Standing with assist (2 pers) Jointly with

PASSES BASIC ASSESSMENT 3 + MRCsum 36 + BBS²

Sitting 1 BODY POSITIONING 4 2hr turning

Active leg and/or arm cycling in chair or

15 BODY POSITIONING 2hr turning Passive transfer bed to chair Sitting out of bed Standing with assist (2 pers) Jointly with nursing staff UZLEUVEN START TO MOVE' ASAP LEVEL 0 LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5 CLOSE TO FULL COOPERATION S5Q 1 4/5 PASSES BASIC ASSESSMENT 3 + MRCsum 36 + BBS² Sit to stand = 0 + BBS² Standing = 0 + BBS² Sitting 1 BODY POSITIONING 4 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 chair or bed Walking (with assistance/frame) NMES ADL 15

NMES: PHYSIO in combination FEEDING Walking >

functional > eating, drinking Logopedy > swallowing

LEVEL 0 LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5

ASSESSMENT 3 + MRCsum 36 + BBS² Sit to stand = 0 +

4 2hr turning Passive transfer bed to chair Sitting

PHYSIOTHERAPY 4 Passive/Active range of motion

16 NMES: PHYSIO in combination FEEDING Walking > adjustment Insuline (discontinuation feeding) ADL > functional > eating, drinking Logopedy > swallowing disorders for eating UZLEUVEN START TO MOVE' ASAP LEVEL 0 LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5 CLOSE TO FULL COOPERATION S5Q 1 4/5 PASSES BASIC ASSESSMENT 3 + MRCsum 36 + BBS² Sit to stand = 0 + BBS² Standing = 0 + BBS² Sitting 1 BODY POSITIONING 4 2hr turning Passive transfer bed to chair Sitting out of bed Standing with assist (2 pers) PHYSIOTHERAPY 4 Passive/Active range of motion Resistance training arms and legs Active leg and/or arm cycling in bed or chair NMES ADL 16

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

17 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. 17

18 ICU Physical Therapy Team THANK YOU! Questions? 18

MOVE IT or LOSE IT EARLY REHABILITATION IN THE ICU: Deconditioning Inactivity. Rik Gosselink, PT,PhD Dept Rehabilitation Sciences KU Leuven

MOVE IT or LOSE IT EARLY REHABILITATION IN THE ICU: Deconditioning Inactivity. Rik Gosselink, PT,PhD Dept Rehabilitation Sciences KU Leuven Deconditioning Inactivity Eal functioning Retained secretions Lung collaps Weaning EARLY REHABILITATION IN THE ICU: Deconditioning Inactivity MOVE IT or LOSE IT Rik Gosselink, PT,PhD Dept Rehabilitation