Kathy Stiller

Physiotherapy in Intensive Care: An Updated Systematic Review

BACKGROUND Although physiotherapy is frequently provided to patients in the ICU, its role has been questioned. The purpose of this systematic literature review, an update of one published in 2000, was to examine the evidence concerning the effectiveness of physiotherapy for adult, intubated patients who are mechanically ventilated in the ICU. METHODS The main literature search was undertaken on PubMed, with secondary searches of MEDLINE, CINAHL, Embase, the Cochrane Library, and the Physiotherapy Evidence Database. Only papers published from 1999 were included. No limitations were placed on study design, intervention type, or outcomes of clinical studies; nonsystematic reviews were excluded. Items were checked for relevance and data extracted from included studies. Marked heterogeneity of design precluded statistical pooling of results and led to a descriptive review. RESULTS Fifty-five clinical and 30 nonclinical studies were reviewed. The evidence from randomized controlled trials evaluating the effectiveness of routine multimodality respiratory physiotherapy is conflicting. Physiotherapy that comprises early progressive mobilization has been shown to be feasible and safe, with data from randomized controlled trials demonstrating that it can improve function and shorten ICU and hospital length of stay. CONCLUSIONS Available new evidence, published since 1999, suggests that physiotherapy intervention that comprises early progressive mobilization is beneficial for adult patients in the ICU in terms of its positive effect on functional ability and its potential to reduce ICU and hospital length of stay. These new findings suggest that early progressive mobilization should be implemented as a matter of priority in all adult ICUs and an area of clinical focus for ICU physiotherapists.

The safety of mobilisation and its effect on haemodynamic and respiratory status of intensive care patients

This study investigated the safety of mobilising acutely ill in-patients, in particular the effect of mobilisation on their haemodynamic and respiratory parameters. Thirty one patients in an intensive care unit (ICU) deemed suitable for mobilisation, based on a comprehensive screening process, received 69 mobilisation treatments in total. These treatments most often included sitting on the edge of the bed and standing. Outcome measures including heart rate, systolic and diastolic blood pressure, and percutaneous saturation of oxygen, were measured prior to, during and after mobilisation. Additionally, any deterioration in clinical status, and intervention required for it, was noted. On the majority of occasions (91.3%), pre-treatment data from patients indicated marginal cardiac and/or respiratory reserve. During mobilisation, significant increases were seen in heart rate and blood pressure, while percutaneous oxygen saturation decreased (not significantly). These changes were generally of small magnitude and did not require any specific intervention. On three of the 69 occasions of mobilisation (4.3%), clinical status deteriorated, requiring intervention. For all three patients involved, this was a fall in oxygen saturation, requiring a temporary increase in the inspired fraction of oxygen to stabilise respiratory status. Although mobilisation resulted in significant increases in heart rate and blood pressure and a non-significant fall in percutaneous oxygen saturation, the ICU patients in this study deemed suitable for mobilisation were able to be safely mobilised.

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.

Acute lobar atelectasis: A comparison of five physiotherapy regimens

Thirty-five patients with acute lobar atelectasis were allocated to one of five treatment groups (seven patients per group). Intubated patients received manual hyperinflation and suction with or without the addition of postural drainage or modified postural drainage and chest wall vibrations. For the non-intubated patients, deep breathing, coughing and huffing replaced the techniques of manual hyperinflation and suction. Frequency of treatment ranged from hourly for 6 h for four groups, to one treatment only for the fifth group. The results suggest that modified postural drainage is an effective additional component to manual hyperinflation and suction performed hourly for 6 h. The addition of chest wall vibrations to this treatment regimen did not further enhance the response to treatment, nor did the use of traditional postural drainage positions. There was evidence that hourly treatment for 6 h using modified postural drainage, manual hyperinflation and suction was more effective than one treatment only.

The sensitivity of three commonly used outcome measures to detect change amongst patients receiving inpatient rehabilitation following stroke.

Objective: To investigate the sensitivity of three commonly used functional outcome measures to detect change over time in subjects receiving inpatient rehabilitation post stroke. Design: Subjects were assessed within one week of admission and one week of discharge from an inpatient rehabilitation facility. Several parameters of sensitivity were calculated, including floor and ceiling effects, the percentage of subjects showing no change and the effect size of the change between admission and discharge. Setting: The medical rehabilitation ward of an inpatient rehabilitation facility. Subjects: Seventy-eight subjects receiving inpatient rehabilitation following a first or recurrent stroke. Measures: Five-metre walk, comfortable pace (gait speed), the Berg Balance Scale and the Motor Assessment Scale. Results: Sixty-one subjects had complete admission and discharge data. Gait speed and the Berg Balance Scale were both sensitive to change and demonstrated large effect sizes. The Motor Assessment Scale item five also showed a large effect size and was able to detect change amongst lower functioning subjects. The other items of the Motor Assessment Scale were less useful, in particular, the effect sizes for upper extremity change scores were small (d=0.36–0.5) and the majority of subjects (44.3–63.9%) showed no change over time on these measures. Conclusion: Gait speed, the Berg Balance Scale and the Motor Assessment Scale item five were sensitive to change over time in this sample.

Does physiotherapy reduce the incidence of postoperative pulmonary complications following pulmonary resection via open thoracotomy? A preliminary randomised single-blind clinical trial

OBJECTIVE This study investigates whether targeted postoperative respiratory physiotherapy decreased the incidence of postoperative pulmonary complications and length of stay for patients undergoing elective pulmonary resection via open thoracotomy. METHODS Seventy-six patients participated in a prospective, single-blind, parallel-group, randomised trial with concealed allocation, assessor blinding and intention-to-treat analysis. Treatment group participants received daily respiratory physiotherapy interventions until discharge. Control group participants received standard medical/nursing care involving a clinical pathway. The presence of postoperative pulmonary complications was assessed on a daily basis during hospitalisation using a standardised diagnostic tool. Length of stay was recorded. RESULTS Postoperative pulmonary complications developed in two participants (4.8%) in the treatment group and in one participant (2.9%) in the control group; the difference (treatment minus control) was 1.8% (95% confidence interval (CI) -10.6% to 13.1%) (p=1.00). No significant difference was found between groups for length of stay (treatment group, median 6.0 days; control group 6.0 days) (p=0.87). A preoperative forced expiratory volume in 1s of 1.5l or less (p=0.005) and a history of chronic obstructive pulmonary disease (p=0.008) were associated with a greater number of criteria for a postoperative pulmonary complication being met. CONCLUSIONS In this patient population, given the low incidence of postoperative pulmonary complications, targeted respiratory physiotherapy may not be required in addition to standard care involving a clinical pathway following pulmonary resection via open thoracotomy. These results should be extrapolated with caution to those patients undergoing pulmonary resection with poor preoperative lung function.

Safety aspects of mobilising acutely ill inpatients

As impaired mobility is an almost inevitable sequelae for patients who are admitted to hospital with an acute life-threatening illness, the physiotherapy management of these patients will often include treatment aimed at maximising mobility and independence. There are many factors that can affect the ability of acutely ill inpatients to tolerate mobilisation, such as their medical background, cardiovascular stability, and respiratory status. Other parameters including haemoglobin, platelet count, white cell count, and more subjective factors, such as the patients appearance, level of pain, and fatigue, also should be considered. The aim of this article is to provide physiotherapists with comprehensive guidelines regarding safety issues that should be considered prior to and while mobilising acutely ill patients.

Are bed exercises necessary following hip arthroplasty

This study investigated whether a program of bed exercises increased the effectiveness of a mobility regimen during the acute period of hospitalisation, for patients who had undergone primary hip arthroplasty. Forty-two patients were randomly allocated, using a concealed allocation procedure, to one of two groups. Patients in the control group were mobilised according to a standard post-operative protocol. Patients in the exercise group were also mobilised using this protocol but in addition received a program of bed exercises. Severity of pain, range of active hip flexion and hip abduction, and a functional assessment were measured by a blinded assessor on the third or fourth post-operative day and again on the seventh or eighth post-operative day. Significant improvements were found in all outcome measures from the third or fourth post-operative day to the seventh or eighth post-operative day. No significant differences were seen between groups for any outcome measures at either measurement time. Bed exercises do not appear to be of additional benefit to a mobility regimen during the period of acute hospitalisation after primary hip arthroplasty.

Physical outcomes of patients with burn injuries--a 12 month follow-up.

There is only limited research documenting functional ability, physical fitness, and health related quality of life after burn injury. The objective of this study was to measure a comprehensive range of physiotherapy-related outcomes over a 12-month period for patients with significant burn injuries. A prospective study was performed on consecutive patients admitted to the Royal Adelaide Hospital over a 12-month period. Outcomes were measured at admission and discharge from hospital and at 1, 3, 6, and 12 months, and comprised the: Medical Outcomes Study 36-Item Short Form Health Survey, Quick Disabilities of the Arm, Shoulder and Hand questionnaire, Lower Extremity Functional Scale questionnaire, shuttle walk test, grip strength and scar appearance using the Matching Assessment with Photographs of Scars. A total of 86 patients (74 male, mean age 38 years) participated. There was a significant deterioration in all outcomes in the first few months after burn injury, with most outcomes improving towards baseline levels by 6 months. However, lower limb function (Lower Extremity Functional Scale) remained significantly reduced at 12 months and functional exercise capacity (shuttle walk test) was still markedly reduced at 6 months compared with predicted normal values. The total burn surface area significantly affected many of the outcomes. In conclusion, for this sample of patients after burn injury, there was an acceptable rate of recovery for physiotherapy-related outcomes, in that most measures had returned to near baseline levels by 6 months postinjury, with the exception of lower limb function and functional exercise capacity.

The prevalence and severity of symptoms of incontinence in adult cystic fibrosis patients

Patients with chronic lung disease are believed to be at an increased risk of developing urinary stress incontinence and/or bowel dysfunction because of the stress that repeated coughing places on the pelvic floor (Jones, Jenkins, & Lee, 1997). The purpose of this study is to document the prevalence, severity, and impact of urinary and faecal incontinence in adult patients with cystic fibrosis (CF). Seventy-one patients (42 males, 29 females) with a mean age of 24.6 years (range 18-44) attending an adult CF unit completed a questionnaire. Eleven female patients (37.9%) reported leaking of urine. The frequency of incontinence ranged from four times a week to episodic incontinence during a pulmonary exacerbation. The amount of urine leaked was at most small, and coughing was identified as the main activity that caused leaking. No females reported faecal incontinence. Two male patients (4.8%) reported incontinence. One of these reported frequent ongoing episodes of leaking small amounts of urine, not associated with coughing, and the other male reported a single incident of faecal incontinence. In general, for females and males, the incontinence was perceived as causing few problems. The prevalence of incontinence in this sample of adult patients with CF was higher than would be expected in a general population of similar age. Further studies are needed to confirm these findings and to evaluate the effectiveness of pelvic floor muscle exercises and rehabilitation in preventing or treating incontinence in patients with CF.