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 Sciences KU Leuven
Mortality and ARDS ProgressofIntensiveCareMedicinehas resulted in significantly improved survival of critically ill patients. ICU treatment: buying time to allow vital systems to recover function is oftentimes associated with prolonged bed rest and inactivity Type I ~ 3% per day Type II ~ 4% per day Limb muscle weakness in critically ill patients Helliwell et al. Neuropathology and Appl Neurobiol. 24, 507-517, 1998.
Respiratory muscle weakness in critically ill patients 95 surgical and medical ICU patients, mechanically ventilated for more than 7 days 25 % had significant muscle weakness at day 7 after awakening Medical Research Counsil Sclae, Mean 5 4 3 2 1 2.9 2.6 ICU Acquired Weakness (MRC sum score less than 48/60) Right side Left side 3.4 3.0 3.0 3.1 3.3 3.3 2.4 2.1 2.0 2.1 0 Shoulder Elbow Wrist Hip Knee Upper extremity Lower extremity Ankle Hermans et al. Crit. Care 2010; 14: R127 De Jonghe B, JAMA 2002
RECOVERY AFTER ARDS 100 %predicted 80 60 40 20 FEV1 6MWD SF-36 PF De Jonghe B, JAMA 2002 0 3 6 12 60 months Herridge et al. N.Engl.J.Med. 2003/2011 at ICU discharge Our results suggest that the inability to exercise is primarily due to extrapulmonary disease; our impression is that impaired muscle function had an important effect on the long-term outcomes in these patients Van der Schaaf et al. Disabil. and Rehabil. 2008: 30:1218 Herridge et al. N.Engl.J.Med. 348:683-693, 2003
Schefold et al. J Cach Sarcop Muscle 2010; 1:147 Iwashyna TJ AJRCCM 2012: 186:302 Thigh muscle layer thickness in critically ill ventilated patients Thigh thickness (cm) ICU stay (days) Gruther et al. J Rehabil Med 2008; 40: 185 189 The physician must always consider complete bed rest as a highly unphysiologic and definitely hazardous form of therapy, to be ordered only for specific indications and discontinued as early as possible. The indications for which bed rest should be prescribed, and for how long, are yet to be defined. Dock W. The evil sequelae of complete bed rest. JAMA 1944; 125:1083 85.
Morris et al. Crit. Care Med. 2008: 36: 2238 Current AND Pre-existent comorbid conditions UZLEUVEN START TO MOVE' ASAP LEVEL 0 LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5 NO NO-LOW MODERATE CLOSE TO FULL FULL FULL S5Q 1 = 0 S5Q 1 < 3 S5Q 1 3 S5Q 1 4/5 S5Q 1 = 5 S5Q 1 = 5 FAILS BASIC ASSESSMENT 2 Stimulus Rest Modality Intensity Duration BASIC Neurological or Obesity or neurological or MRCsum 36 + MRCsum 48 + ASSESSMENT = surgical or trauma surgical or trauma BBS² Sit to stand = 0 + condition does not BBS² Sit to stand 0 + condition does not allow - Cardiorespiratory allow transfer to chair active transfer to chair BBS² Standing = 0 + BBS² Standing 0 + unstable: (even if MRCsum 36) BBS² Sitting 1 BBS² Sitting 2 MAP < 60mmHg or BODY BODY POSITIONING 4 BODY POSITIONING FiO 4 2 > 60% or POSITIONING 4 BODY POSITIONING 4 2hr turning 2hr turning PaO 2/FiO 2 < 200 or 2hr turning Active transfer bed to Splinting Passive transfer bed to chair RR > 30 bpm Fowler s position Upright sitting position in chair Sitting out of bed - Neurologically Splinting bed Sitting out of bed unstable Standing with assist ( 1 Passive transfer bed to PHYSIOTHERAPY 4 Standing with assist (2 pers) -Acute surgery chair pers) Passive range of PHYSIOTHERAPY -Temp > 40 C 4 PHYSIOTHERAPY 4 PHYSIOTHERAPY 4 Passive/Active range of BODY Passive bed cycling Passive/Active range of Passive/Active range of POSITIONING 4 Resistance training 2hr turning Resistance training arms arms and legs Resistance training arms and legs PHYSIOTHERAPY: and legs Active leg and/or arm Passive/Active leg and/or cycling in chair or bed No treatment Active leg and/or arm cycling in bed or chair cycling in bed or chair Walking (with assistance/frame) ADL ADL 1 : score 5 questions: adequate response to 5 standardized orders 2 : FAILS = at least 1 risk factor present / 3 : if basic assessment failed, decrease to level 0 4 : safety: each activity should be deferred if severe adverse events (cv., resp. and subject. intolerance) occur during the intervention MRCsum 48 + BBS² Sit to stand 1 + BBS² Standing 2 + BBS² Sitting 3 BODY POSITIONING 4 Active transfer bed to chair Sitting out of bed Standing PHYSIOTHERAPY 4 Passive/Active range of Resistance training arms and legs Active leg and arm cycling in chair Walking (with assistance) ADL
ASSESSMENT: Cardiorespiratory status MAP >60 or <120 (vasoactive medication?) Heart Rate >50/min or <140/min, SaO2>85% FiO 2 < 0.60 Respiratory Rate < 30/min PEEP < 10 cmh 2 O Body temperature <40 C Assistant devices (cardiorespiratory, renal) ASSESSMENT OF (JOINT) MOBILITY: Immobility Surgery - Trauma Obesity Drains Devices ASSESSMENT: Neurological status Glasgow Coma Scale Adequacy/level of cooperation: S5Q VOLITIONAL MANEUVERS: MRC 0-5 DYNAMOMETRY NONVOLITIONAL MANEUVERS: MUSCLE TWITCH STIMULATION FORCE MUSCLE MASS (ULTRASOUND CT/MRI)
Objective measures for muscle strength MRC 3 Dynamometry Isometric muscle testing Handgrip dynamometry Hand-held Dynamometry Intertester reliability HHD (range ICC : 0.76-0.97) Isometric contraction MAKE test Electronic hand held device Normative data ICC : 0.91 ICC: 0.94 Vanpee G, Segers J et al. Crit Care Med 2011
Current AND Pre-existent comorbid conditions GET THE PATIENT UPRIGHT AND MOVING Stimulus Rest Modality Intensity Duration MODALTIES FOR PHYSICAL TRAINING STABLE-COOPERATIVE Exercise training Mobilisation Body positioning Active muscle (resistance) training Transcutaneous electrical muscle stimulation Passive stretching and range of exercise UNSTABLE-BED RIDDEN-UNCOOPERATIVE
Morris et al. Crit. Care Med. 2008: 36: 2238 20 15 * Critically ill patient < 48 hours MV Daily Mobility Team Interventions (n=165) Usual care: Physical Therapy on physician order (n=166) Morris et al. Crit. Care Med. 2008: 36: 2238 Days (median) 10 5 0 * # First Out Bed Ventilator ICU LOS Hospital LOS Usual Care Mobility Team Morris et al. Crit. Care Med. 2008;36: 2238
Daily Physical and/or Occupational Therapy Critically ill patient < 72 hours MV and forecast of at least another 24hour on MV Barthel Index > 70 (max 100) in 2 weeks before admission Usual care: Physical and/or Occupational Therapy on physician order Schweikert et al. Lancet 2009; 373:1874-1882? Schweikert et al. Lancet 2009; 373:1874-1882 Morris et al. Crit. Care Med. 2008: 36: 2238
Barriers for advanced mobilization Bourdin et al. Respir. Care 2010: 55:400 Garzon_Serrano et al. PMR 2011: 3:307-311 Team work! Garzon_Serrano et al. PMR 2011: 3:307-311
1 : score 5 questions: adequate response to 5 standardized orders UZLEUVEN START TO MOVE' ASAP LEVEL 0 LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5 NO S5Q 1 = 0 FAILS BASIC ASSESSMENT 2 BASIC ASSESSMENT = - Cardiorespiratory unstable: MAP < 60mmHg or FiO 2 > 60% or PaO 2/FiO 2 < 200 or RR > 30 bpm - Neurologically unstable -Acute surgery -Temp > 40 C BODY POSITIONING 4 2hr turning PHYSIOTHERAPY: No treatment NO-LOW S5Q 1 < 3 Neurological or surgical or trauma condition does not allow transfer to chair BODY POSITIONING 4 2hr turning Fowler s position Splinting PHYSIOTHERAPY 4 Passive range of Passive bed cycling MODERATE S5Q 1 3 Obesity or neurological or surgical or trauma condition does not allow active transfer to chair (even if MRCsum 36) BODY POSITIONING 4 2hr turning Splinting Upright sitting position in bed Passive transfer bed to chair PHYSIOTHERAPY 4 Passive/Active range of Resistance training arms and legs Passive/Active leg and/or cycling in bed or chair CLOSE TO FULL S5Q 1 4/5 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 Resistance training arms and legs Active leg and/or arm cycling in bed or chair ADL FULL S5Q 1 = 5 MRCsum 48 + BBS² Sit to stand 0 + BBS² Standing 0 + BBS² Sitting 2 BODY POSITIONING 4 Active transfer bed to chair Sitting out of bed Standing with assist ( 1 pers) PHYSIOTHERAPY 4 Passive/Active range of Resistance training arms and legs Active leg and/or arm cycling in chair or bed Walking (with assistance/frame) ADL FULL S5Q 1 = 5 MRCsum 48 + BBS² Sit to stand 1 + BBS² Standing 2 + BBS² Sitting 3 BODY POSITIONING 4 Active transfer bed to chair Sitting out of bed Standing PHYSIOTHERAPY 4 Passive/Active range of Resistance training arms and legs Active leg and arm cycling in chair Walking (with assistance) ADL Effect of passive stretching on the wasting of muscle in the critically ill Griffiths et al. Nutrition 1995; 11:428-432 2 : FAILS = at least 1 risk factor present / 3 : if basic assessment failed, decrease to level 0 4 : safety: each activity should be deferred if severe adverse events (cv., resp. and subject. intolerance) occur during the intervention MODALTIES FOR PHYSICAL TRAINING CHRONIC-STABLE- COOPERATIVE Exercise training Mobilisation Body positioning Active muscle (resistance) training Transcutaneous electrical muscle stimulation Passive stretching and range of of exercise ACUTE-INSTABLE- UNCOOPERATIVE Protocol 1 leg 3 hours passive, 3 times per day, mainly ankle (25% passive stretch Ant.Tibialis) 1 leg flat position twice daily passive (5 min) both legs
140% p< 0.02 (more severe) Study design % change fiber area 120% 100% 80% 60% 40% 20% 0% Con1 Con2 CPM1 CPM2 1 2 3 4 less severe 5 7 critically ill patient 0-3 days ICU and forecast of at least 10 days at the ICU Passive stretching 10 h per day in addition to Usual care Usual care: respiratory physiotherapy mobilisation Griffiths et al. Nutrition 1995; 11:428-432 Llano-Diez et al. Crit Care 2012; 16:2499-2505 Protocol 1 leg 2.5 hours passive, 4 times per day, mainly ankle (30 pl flexion to 25 dors flexion speed 150 /min) 1 leg flat position
Llano-Diez et al. Crit Care 2012; 16:2499-2505 Reck MOTOmed Movement Therapy Systems, Germany Study 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 Llano-Diez et al. Crit Care 2012; 16:2499-2505 Burtin et al. Crit Care Med 2009; 37:2499-2505
ICU and Hospital stay MODALTIES FOR PHYSICAL TRAINING 45 40 CHRONIC-STABLE- COOPERATIVE Days 35 30 25 20 15 10 Control Treatment Exercise training Mobilisation Body positioning Active muscle (resistance) training Transcutaneous electrical muscle stimulation Passive range of exercise 5 0 ICU stay Hospital stay ACUTE-INSTABLE- UNCOOPERATIVE 6MWD (m) SF-36 PF score (10-30) 600 500 p < 0.05 43 m 400 300 200 100 0 TR CO 196 [126-329] m 143 [37-226] m 30 p < 0.05 25 20 15 10 TR CO 21 [18-23] 15 [14-23] points QF (N/kg) p < 0.01 3.0 p < 0.05 2.5 2.0 1.5 1.0 TR CO TR CO ICU discharge hospital discharge Burtin et al. Crit Care Med 2009 26 patients with APACHE II score > 13 Bilateral ES to quadriceps and peroneus longus Muscle mass evaluation with ultrasound before and after 7 days of intervention Patients with oedema were excluded Gerovasili V, Crit Care 2009 Relative change in CSD (%) Change in CSD (cm) 0-10 -20-30 -40-0.0-0.1-0.2-0.3-0.4-0.5-0.6 RF RF * * VI * p < 0.05 * * VI
Poulsen et al. Crit Care Med 39:456-461 Poulsen et al. Crit Care Med 39:456-461 2 CONCLUSIONS I Day 0 Day 7 Poulsen et al. Crit Care Med 39:456-461 2 CRITICAL ILLNESS IS ASSOCIATED WITH SHORT (AND LONG) TERM MORBIDITY (MUSCLE WEAKNESS, FUNCTIONAL STATUS) THERE IS A VARIETY OF EVIDENCE BASED EXERCISE MODALITIES AVAILABLE FOR EARLY STAGES OF CRITICAL ILLNESS THAT FACILITATE FUNCTIONAL OUTCOME
CONCLUSIONS II TREATMENT SHOULD BE ADMINISTERED JOINTLY BETWEEN MEDICAL, PHYSICAL THERAPY AND NURSING STAFF. Acknowledgements ICU PHYSICAL THERAPY TEAM 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. CONCLUSIONS III RESEARCH SHOULD BE CONDUCTED TO FURTHER ESTABLISH THE EFFECTIVENESS OF EXERCISE MODALITIES IN PATIENTS WITH CRITICAL ILLNESS ON MUSCLE FUNCTION, QOL AND PHYSICAL FUNCTION