Mortality and ARDS EARLY REHABILITATION IN THE ICU: MOVE IT or LOSE IT Progress of Intensive Care Medicine has resulted in significantly improved survival of cri:cally ill pa:ents. Rik Gosselink Dept Rehabilita>on Sciences KU Leuven ICU treatment: buying time to allow vital systems to recover function is oftentimes associated with Deconditioning Inactivity prolonged bed rest and inactivity
Type I ~ 3% per day Limb muscle weakness in critically ill patients Type II ~ 4% per day Helliwell et al. Neuropathology and Appl Neurobiol. 24, 507-517, 1998. Respiratory muscle weakness in cri3cally ill pa3ents Is muscle weakness of clinical relevance?. Hermans et al. Crit. Care 2010; 14: R127 Truong, Crit Care, 2009
Thigh muscle layer thickness in critically ill ventilated patients Thigh thickness (cm) ICU stay (days) Schefold et al. J Cach Sarcop Muscle 2010; 1:147 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. Iwashyna TJ AJRCCM 2012: 186:302
Current AND Pre-existent comorbid conditions Stimulus Rest Modality Intensity Duration 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 Morris et al. Crit. Care Med. 2008: 36: 2238 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 Standing with assist (2 pers) - Acute surgery chair pers) Passive range of PHYSIOTHERAPY -Temp > 40 C 4 Passive/Active range of BODY Passive bed cycling Passive/Active range of Passive/Active range of POSITIONING 4 2hr turning PHYSIOTHERAPY: 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 Passive/Active range of Active leg and arm cycling in chair Walking (with assistance) ADL
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 GET THE PATIENT UPRIGHT AND MOVING
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 Morris et al. Crit. Care Med. 2008: 36: 2238 * Days (median) * # 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 Daily Physical and/or Occupational Therapy Usual care: Physical and/or Occupational Therapy on physician order Morris et al. Crit. Care Med. 2008;36: 2238
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 Bourdin et al. Respir. Care 2010: 55:400
Barriers for advanced mobilization Garzon_Serrano et al. PMR 2011: 3:307-311 Garzon_Serrano et al. PMR 2011: 3:307-311 Quality improvement in ICU Rehabilitation UZLEUVEN START TO MOVE' ASAP LEVEL 0 LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5 100 90 80 70 60 50 40 30 20 10 0 Days without PT PT consult Days with alertness Days without delirium Functional mobility Before QI After QI 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 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 Passive/Active range of 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) Passive/Active range of 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) Passive/Active range of 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 Passive/Active range of Active leg and arm cycling in chair Walking (with assistance) ADL Needham et al. Top Stroke Rehab 2010: 17:271-281 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
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 Effect of passive stretching on the wasting of muscle in the critically ill Griffiths et al. Nutrition 1995; 11:428-432 Protocol p< 0.02 (more severe) l 1 leg 3 hours passive, 3 times per day, mainly ankle (25% passive stretch Ant.Tibialis) l 1 leg flat position l twice daily passive (5 min) both legs % change fiber area 140% 120% 100% 80% 60% 40% 20% 1 2 3 4 less severe 5 0% Con1 Con2 CPM1 CPM2 Griffiths et al. Nutrition 1995; 11:428-432
Study design 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 Llano-Diez et al. Crit Care 2012; 16:2499-2505 Protocol l 1 leg 2.5 hours passive, 4 times per day, mainly ankle (30 pl flexion to 25 dors flexion speed 150 /min) l 1 leg flat position Llano-Diez et al. Crit Care 2012; 16:2499-2505
Llano-Diez et al. Crit Care 2012; 16:2499-2505 Active vs. Passive Cycling 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 Burtin et al. Crit Care Med 2009; 37:2499-2505 Mean Resistance 0.7 ± 1.2 Watt 3.2 ± 1.5 Watt
Cardiorespiratory responses ICU and Hospital stay 45 40 35 30 * * * p < 0.05 vs. start Days 25 20 15 10 Control Treatment 5 0 ICU stay Hospital stay 43 m p < 0.01 p < 0.05 196 [126-329] m 143 [37-226] m 21 [18-23] 15 [14-23] points Burtin et al. Crit Care Med 2009
MODALTIES FOR PHYSICAL TRAINING CHRONIC-STABLE- COOPERATIVE Exercise training Mobilisation Body positioning Active muscle (resistance) training Transcutaneous electrical muscle stimulation Passive range of exercise Camargo et al PLOSone 2013 ACUTE-INSTABLE- UNCOOPERATIVE v 26 patients with APACHE II score > 13 v Bilateral ES to quadriceps and peroneus longus v Muscle mass evaluation with ultrasound before and after 7 days of intervention RF * * p < 0.05 VI * v Patients with oedema were excluded * * RF VI Gerovasili V, Crit Care 2009
Poulsen et al. Crit Care Med 39:456-461 Poulsen et al. Crit Care Med 39:456-461 2 IS SUCCESSFUL IN ICU PATIENTS? Segers et al. ATS Philadelphia 2013
CONCLUSIONS II CONCLUSIONS I 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 TREATMENT SHOULD BE ADMINISTERED JOINTLY BETWEEN MEDICAL, PHYSICAL THERAPY AND NURSING STAFF. l T H E P H Y S I C A L T H E R A P I S T S H O U L D B E 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 Acknowledgements ICU PHYSICAL THERAPY TEAM