Elizabeth H. Skinner

Exercise rehabilitation for patients with critical illness: a randomized controlled trial with 12 months of follow-up

IntroductionThe purpose of this trial was to investigate the effectiveness of an exercise rehabilitation program commencing during ICU admission and continuing into the outpatient setting compared with usual care on physical function and health-related quality of life in ICU survivors.MethodsWe conducted a single-center, assessor-blinded, randomized controlled trial. One hundred and fifty participants were stratified and randomized to receive usual care or intervention if they were in the ICU for 5 days or more and had no permanent neurological insult. The intervention group received intensive exercises in the ICU and the ward and as outpatients. Participants were assessed at recruitment, ICU admission, hospital discharge and at 3-, 6- and 12-month follow-up. Physical function was evaluated using the Six-Minute Walk Test (6MWT) (primary outcome), the Timed Up and Go Test and the Physical Function in ICU Test. Patient-reported outcomes were measured using the Short Form 36 Health Survey, version 2 (SF-36v2) and Assessment of Quality of Life (AQoL) Instrument. Data were analyzed using mixed models.ResultsThe a priori enrollment goal was not reached. There were no between-group differences in demographic and hospital data, including acuity and length of acute hospital stay (LOS) (Acute Physiology and Chronic Health Evaluation II score: 21 vs 19; hospital LOS: 20 vs 24 days). No significant differences were found for the primary outcome of 6MWT or any other outcomes at 12 months after ICU discharge. However, exploratory analyses showed the rate of change over time and mean between-group differences in 6MWT from first assessment were greater in the intervention group.ConclusionsFurther research examining the trajectory of improvement with rehabilitation is warranted in this population.Trial registrationThe trial was registered with the Australian New Zealand Clinical Trials Registry ACTRN12605000776606.

Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults.

IntroductionThe aim of this study was to develop consensus recommendations on safety parameters for mobilizing adult, mechanically ventilated, intensive care unit (ICU) patients.MethodsA systematic literature review was followed by a meeting of 23 multidisciplinary ICU experts to seek consensus regarding the safe mobilization of mechanically ventilated patients.ResultsSafety considerations were summarized in four categories: respiratory, cardiovascular, neurological and other. Consensus was achieved on all criteria for safe mobilization, with the exception being levels of vasoactive agents. Intubation via an endotracheal tube was not a contraindication to early mobilization and a fraction of inspired oxygen less than 0.6 with a percutaneous oxygen saturation more than 90% and a respiratory rate less than 30 breaths/minute were considered safe criteria for in- and out-of-bed mobilization if there were no other contraindications. At an international meeting, 94 multidisciplinary ICU clinicians concurred with the proposed recommendations.ConclusionConsensus recommendations regarding safety criteria for mobilization of adult, mechanically ventilated patients in the ICU have the potential to guide ICU rehabilitation whilst minimizing the risk of adverse events.

Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study.

The aim of this study was to investigate current mobilization practice, strength at ICU discharge and functional recovery at 6 months among mechanically ventilated ICU patients. This was a prospective, multi-centre, cohort study conducted in twelve ICUs in Australia and New Zealand. Patients were previously functionally independent and expected to be ventilated for >48 hours. We measured mobilization during invasive ventilation, sedation depth using the Richmond Agitation and Sedation Scale (RASS), co-interventions, duration of mechanical ventilation, ICU-acquired weakness (ICUAW) at ICU discharge, mortality at day 90, and 6-month functional recovery including return to work. We studied 192 patients (mean age 58.1 ± 15.8 years; mean Acute Physiology and Chronic Health Evaluation (APACHE) (IQR) II score, 18.0 (14 to 24)). Mortality at day 90 was 26.6% (51/192). Over 1,351 study days, we collected information during 1,288 planned early mobilization episodes in patients on mechanical ventilation for the first 14 days or until extubation (whichever occurred first). We recorded the highest level of early mobilization. Despite the presence of dedicated physical therapy staff, no mobilization occurred in 1,079 (84%) of these episodes. Where mobilization occurred, the maximum levels of mobilization were exercises in bed (N = 94, 7%), standing at the bed side (N = 11, 0.9%) or walking (N = 26, 2%). On day three, all patients who were mobilized were mechanically ventilated via an endotracheal tube (N = 10), whereas by day five 50% of the patients mobilized were mechanically ventilated via a tracheostomy tube (N = 18). In 94 of the 156 ICU survivors, strength was assessed at ICU discharge and 48 (52%) had ICU-acquired weakness (Medical Research Council Manual Muscle Test Sum Score (MRC-SS) score <48/60). The MRC-SS score was higher in those patients who mobilized while mechanically ventilated (50.0 ± 11.2 versus 42.0 ± 10.8, P = 0.003). Patients who survived to ICU discharge but who had died by day 90 had a mean MRC score of 28.9 ± 13.2 compared with 44.9 ± 11.4 for day-90 survivors (P <0.0001). Early mobilization of patients receiving mechanical ventilation was uncommon. More than 50% of patients discharged from the ICU had developed ICU-acquired weakness, which was associated with death between ICU discharge and day-90. ClinicalTrials.gov NCT01674608. Registered 14 August 2012.

A Physical Function Test for Use in the Intensive Care Unit: Validity, Responsiveness, and Predictive Utility of the Physical Function ICU Test (Scored)

Background Several tests have recently been developed to measure changes in patient strength and functional outcomes in the intensive care unit (ICU). The original Physical Function ICU Test (PFIT) demonstrates reliability and sensitivity. Objective The aims of this study were to further develop the original PFIT, to derive an interval score (the PFIT-s), and to test the clinimetric properties of the PFIT-s. Design A nested cohort study was conducted. Methods One hundred forty-four and 116 participants performed the PFIT at ICU admission and discharge, respectively. Original test components were modified using principal component analysis. Rasch analysis examined the unidimensionality of the PFIT, and an interval score was derived. Correlations tested validity, and multiple regression analyses investigated predictive ability. Responsiveness was assessed using the effect size index (ESI), and the minimal clinically important difference (MCID) was calculated. Results The shoulder lift component was removed. Unidimensionality of combined admission and discharge PFIT-s scores was confirmed. The PFIT-s displayed moderate convergent validity with the Timed “Up & Go” Test (r=−.60), the Six-Minute Walk Test (r=.41), and the Medical Research Council (MRC) sum score (rho=.49). The ESI of the PFIT-s was 0.82, and the MCID was 1.5 points (interval scale range=0–10). A higher admission PFIT-s score was predictive of: an MRC score of ≥48, increased likelihood of discharge home, reduced likelihood of discharge to inpatient rehabilitation, and reduced acute care hospital length of stay. Limitations Scoring of sit-to-stand assistance required is subjective, and cadence cutpoints used may not be generalizable. Conclusions The PFIT-s is a safe and inexpensive test of physical function with high clinical utility. It is valid, responsive to change, and predictive of key outcomes. It is recommended that the PFIT-s be adopted to test physical function in the ICU.

Safety and Feasibility of an Exercise Prescription Approach to Rehabilitation Across the Continuum of Care for Survivors of Critical Illness

Background Survivors of critical illness can experience long-standing functional limitations that negatively affect their health-related quality of life. To date, no model of rehabilitation has demonstrated sustained improvements in physical function for survivors of critical illness beyond hospital discharge. Objective The aims of this study were: (1) to describe a model of rehabilitation for survivors of critical illness, (2) to compare the model to local standard care, and (3) to report the safety and feasibility of the program. Design This was a cohort study. Methods As part of a larger randomized controlled trial, 74 participants were randomly assigned, 5 days following admission to the intensive care unit (ICU), to a protocolized rehabilitation program that commenced in the ICU and continued on the acute care ward and for a further 8 weeks following hospital discharge as an outpatient program. Exercise training was prescribed based on quantitative outcome measures to achieve a physiological training response. Results During acute hospitalization, 60% of exercise sessions were able to be delivered. The most frequently occurring barriers to exercise were patient safety and patient refusal due to fatigue. Point prevalence data showed patients were mobilized more often and for longer periods compared with standard care. Outpatient classes were poorly attended, with only 41% of the patients completing more than 70% of outpatient classes. No adverse events occurred. Limitations Limitations included patient heterogeneity and delayed commencement of exercise in the ICU due to issues of consent and recruitment. Conclusions Exercise training that commences in the ICU and continues through to an outpatient program is safe and feasible for survivors of critical illness. Models of care that maximize patient participation across the continuum of care warrant further investigation.

Association of postoperative pulmonary complications with delayed mobilisation following major abdominal surgery: an observational cohort study

OBJECTIVES Previous Australian studies reported that postoperative pulmonary complications affect 13% of patients undergoing upper abdominal laparotomy. This study measured the incidence of postoperative pulmonary complications, risk factors for the diagnosis of postoperative pulmonary complications and barriers to physiotherapy mobilisation in a cohort of patients undergoing high-risk abdominal surgery. DESIGN Prospective, observational cohort study. SETTING Two surgical wards in a tertiary Australian hospital. PARTICIPANTS Seventy-two patients undergoing high-risk abdominal surgery (participants in a larger trial evaluating a novel model of medical co-management). MAIN OUTCOME MEASURES Incidence of, and risk factors for, postoperative pulmonary complications, barriers to mobilisation and length of stay. RESULTS The incidence of postoperative pulmonary complications was 39%. Incision type and time to mobilise away from the bed were independently associated with a diagnosis of postoperative pulmonary complications. Patients were 3.0 (95% confidence interval 1.2 to 8.0) times more likely to develop a postoperative pulmonary complication for each postoperative day they did not mobilise away from the bed. Fifty-two percent of patients had a barrier to mobilisation away from the bed on the first postoperative day, with the most common barrier being hypotension, although cessation criteria were not defined objectively by physiotherapists. Development of a postoperative pulmonary complication increased median hospital length of stay (16 vs 13 days; P=0.046). CONCLUSIONS This study demonstrated an association between delayed postoperative mobilisation and postoperative pulmonary complications. Randomised controlled trials are required to test the role of early mobilisation in preventing postoperative pulmonary complications in patients undergoing high-risk upper abdominal surgery.

Closing the Gap Between Ethics Knowledge and Practice Through Active Engagement: An Applied Model of Physical Therapy Ethics

Physical therapist practice has a distinct focus that is holistic (ie, patient centered) and at the same time connected to a range of other providers within health care systems. Although there is a growing body of literature in physical therapy ethics knowledge, including clinical obligations and underlying philosophical principles, less is known about the unique ethical issues that physical therapists encounter, and how and why they make ethical decisions. As moral agents, physical therapists are required to make autonomous clinical and ethical decisions based on connections and relationships with their patients, other health care team members, and health institutions and policies. This article identifies specific ethical dimensions of physical therapist practice and highlights the development and focus of ethics knowledge in physical therapy over the last several decades. An applied ethics model, called the “active engagement model,” is proposed to integrate clinical and ethical dimensions of practice with the theoretical knowledge and literature about ethics. The active engagement model has 3 practical steps: to listen actively, to think reflexively, and to reason critically. The model focuses on the underlying skills, attitudes, and actions that are required to build a sense of moral agency and purpose within physical therapist practice and to decrease gaps between the ethical dimensions of physical therapist practice and physical therapy ethics knowledge and scholarship. A clinical case study is provided to illustrate how the ethics engagement model might be used to analyze and provide insight into the ethical dimensions of physical therapist practice.

Psychosocial Outcomes in Informal Caregivers of the Critically Ill: A Systematic Review

Objective: The objective of the review was to evaluate and synthesize the prevalence, risk factors, and trajectory of psychosocial morbidity in informal caregivers of critical care survivors. Data Sources: A systematic search of MEDLINE, PsychInfo, PubMed, CINAHL, Cochrane Library, Scopus, PILOTS, EMBASE, and Physiotherapy Evidence Database was undertaken between January and February 2014. Study Selection: Citations were screened independently by two reviewers for studies that investigated psychosocial outcomes (depression, anxiety, stress, posttraumatic stress disorder, burden, activity restriction, and health-related quality of life) for informal caregivers of critical care survivors (mechanically ventilated for 48 hr or more). Data Extraction: Data on study outcomes were extracted into a standardized form and quality assessed by two independent reviewers using the Newcastle-Ottawa Scale, the Physiotherapy Evidence Database, and the National Health and Medical Research Council Hierarchy of Evidence guide. Preferred Reporting Items for Systematic Reviews guidelines were followed. Data Synthesis: Fourteen studies of 1,491 caregivers were included. Depressive symptoms were the most commonly reported outcome with a prevalence of 75.5% during critical care and 22.8–29% at 1-year follow-up. Risk factors for depressive symptoms in caregivers included female gender and younger age. The greatest period of risk for all outcomes was during the patient’s critical care admission although psychological symptoms improved over time. The overall quality of the studies was low. Conclusions: Depressive symptoms were the most prevalent in informal caregivers of survivors of intensive care who were ventilated for more than 48 hours and persist at 1 year with a prevalence of 22.8–29.0%, which is comparable with caregivers of patients with dementia. Screening for caregiver risks could be performed during the ICU admission where intervention can be implemented and then evaluated. Further high-quality studies are needed to quantify anxiety, stress, caregiver burden, and posttraumatic stress disorder outcomes in informal caregivers of long-stay patients surviving ICU.

A Binational Multicenter Pilot Feasibility Randomized Controlled Trial of Early Goal-Directed Mobilization in the ICU*

Objectives:To determine if the early goal-directed mobilization intervention could be delivered to patients receiving mechanical ventilation with increased maximal levels of activity compared with standard care. Design:A pilot randomized controlled trial. Setting:Five ICUs in Australia and New Zealand. Participants:Fifty critically ill adults mechanically ventilated for greater than 24 hours. Intervention:Patients were randomly assigned to either early goal-directed mobilization (intervention) or to standard care (control). Early goal-directed mobilization comprised functional rehabilitation treatment conducted at the highest level of activity possible for that patient assessed by the ICU mobility scale while receiving mechanical ventilation. Measurements and Main Results:The ICU mobility scale, strength, ventilation duration, ICU and hospital length of stay, and total inpatient (acute and rehabilitation) stay as well as 6-month post-ICU discharge health-related quality of life, activities of daily living, and anxiety and depression were recorded. The mean age was 61 years and 60% were men. The highest level of activity (ICU mobility scale) recorded during the ICU stay between the intervention and control groups was mean (95% CI) 7.3 (6.3–8.3) versus 5.9 (4.9–6.9), p = 0.05. The proportion of patients who walked in ICU was almost doubled with early goal-directed mobilization (intervention n = 19 [66%] vs control n = 8 [38%]; p = 0.05). There was no difference in total inpatient stay (d) between the intervention versus control groups (20 [15–35] vs 34 [18–43]; p = 0.37). There were no adverse events. Conclusions:Key Practice Points: Delivery of early goal-directed mobilization within a randomized controlled trial was feasible, safe and resulted in increased duration and level of active exercises.

Evaluation of Exercise Rehabilitation for Survivors of Intensive Care: Protocol for a Single Blind Randomised Controlled Trial

Introduction: Intensive care (ICU) survivors have poor quality of life (QoL) and physical outcomes compared to people of the same age and sex (1). Although rehabilitation of patients in ICU is now advocated as routine clinical prac- tice (2) there are few randomised controlled trials (RCTs) examining patient outcomes. The primary aim of this single blind randomised controlled trial is to investigate the efficacy of a comprehensive rehabilitation intervention begun in ICU compared to standard care on health related quality of life (HRQoL) and physical function. Method: Participants who have been in one tertiary ICU for � 5 days, aged � 18 years, who can understand written and spoken English, will be randomly allocated to receive either standard care or a comprehensive physiotherapy rehabilita- tion program beginning in ICU and continuing upon discharge to the ward and as an out patient (OP). Blinded assessment of the primary outcome measures physical function, health status and HRQoL will be performed at baseline, 3, 6 and 12 months after discharge. Physical function measures will be obtained at ICU and hospital discharge and for the intervention group, pre and post OP classes. The intervention will include individualised exercises prescribed by physiotherapists in ICU and on the ward and given by an exercise physiologist and physiotherapist in OP. Results: We aim to enrol 200 participants over two years. The study will determine whether comprehensive physiotherapy rehabilitation from ICU to discharge and OP attendance will improve physical functioning, health status and quality of life in critical care survivors. The cost utility (CUA) and cost effectiveness of such a program will also be evaluated using util- ity scores and a purpose designed economics questionnaire. Secondary outcomes related to proxy and subject HRQoL comparisons, mechanical ventilation, critical illness neuromyopathy, ICU readmission and discharge destination will also be examined. Conclusion: The outcomes measured are of significance to critical care patients. The CUA of the intervention will be of interest to health service providers. The results will enable development of clinical practice guidelines for the appropriate exercises in survivors of ICU. Registered with the Australian and New Zealand Clinical Trials Network (ACTRN 12605000776606).