ICU (FS-15)

Physiotherapy in the ICU: current evidence and practical applications

Michelle Kho (Canada), Bronwen Connolly (United Kingdom), Selina Parry (Australia), Jennifer Zanni (United States of America)

Focused symposium

Monday 4 May 2015, 13:45-15:15, Hall 406

Physiotherapy in the ICU: current evidence and practical applications

Kho M. 1,2, Connolly B. 3, Parry S. 4, Zanni J. 2,5

1McMaster University, School of Rehablitation Science, Hamilton, Canada, 2Johns Hopkins University, Physical Medicine and Rehabilitation, Baltimore, United States of America, 3King's College London, Division of Asthma, Allergy and Lung Biology, London, United Kingdom, 4The University of Melbourne, Physiotherapy, Melbourne, Australia, 5Johns Hopkins Hospital, Physical Medicine and Rehabilitation, Baltimore, United States of America

Learning objectives

  1. Understand the evidence and rationale underpinning physiotherapy rehabilitation in the critically ill
  2. Understand the different outcomes used to measure patient progress
  3. Critically appraise and synthesize evidence, and use clinical decision making strategies to implement appropriate rehabilitation interventions

Description

Advances in medical care and intensive care unit (ICU) practices have led to improved survival in patients with critical illness, including those with complex co-morbidity. As a result, physical and psychological complications associated with critical illness are now far more prevalent. Furthermore, recent literature now well documents that many survivors of critical illness develop strength, functional, cognitive and health-related quality of life impairments which can last for years following their ICU stay (1-4). This condition is newly recognized as post intensive care syndrome (5).

Skeletal muscle weakness resulting from protracted periods of sedation and relative immobilization whist in the ICU, gives rise to much of the physical limitation in patients as they start to recover. Patients with the most severe illness are known to be most affected (6), thus identification of clinically feasible techniques for monitoring and treating muscle loss, strength, and function in these patients is crucial for delivering timely and effective interventions (7).

A significant body of evidence has emerged demonstrating that early mobilisation of patients within the ICU is safe, effective and beneficial (8-12). This is often characterised by a 'hierarchical progression' of techniques from passive movement to bed mobility, sitting, sit-to-stand, bed-to- chair transfers, marching on the spot, and ultimately walking (13). In addition, the reliability and feasibility of mobility-based functional outcome measures has been demonstrated. Choosing an appropriate outcome measure for use in clinical practice or research depends on the clinimetric properties of such measures, their applicability to the treatment aims, and their feasibility in the population of interest (13).

Comprehensive early rehabilitation, commencing from ICU admission and continuing throughout the hospital stay, has been shown to reduce ICU length of stay, improve functional performance status at hospital discharge and is more likely to result in discharge home (10).

The focus of this presentation is to highlight the evidence supporting early physiotherapy and mobility in patients with critical illness, discuss clinical decision-making guidelines, outcome assessment and appropriate outcome measures. We will highlight ongoing clinical trials in this population.

We will discuss the following topics:

 

  • Why do individuals in the ICU need physiotherapy interventions? (B. Connolly)
  • What is the current state of the evidence for physiotherapy rehabilitation in the ICU? (M. Kho)
  • Choosing and using outcome measures in the ICU (S. Parry)
  • Using evidence-based interventions: Clinical applications and decision-making in the ICU (J. Zanni)

References:

 

1. Am J Resp Crit Care Med 2006;174:538-544; 2. Critical Care 2010;14:R6; 3. N Engl J Med 2011;364:1293-1304; 4. Am J Respir Crit Care Med 2005;171:340-347; 5. Critical Care Med 2012; 40(2):502-9; 6. Am J Respir Crit Care Med 2011;183:A2376; 7. Critical Care 2013;In Press; 8. Crit Care Med 2007;35:139-145; 9. Phys Ther 2012; 10. Crit Care Med 2009;37:2499-2505; 11. Lancet 2009;373:1874-1882; 12. Crit Care Clin 2007;23:35-53. 13. Phys Ther 2013; In press.

Implications / Conclusions

We have an urgent need to improve the rehabilitation and outcomes of an increasing number of ICU survivors. By 2026, as the baby boomer generation ages, the demand for ICU services is projected to increase by 40% compared to 2011. More survivors will be at risk of disability post-critical illness, and may develop post intensive care syndrome. As a consequence, there will be widespread and increasing pressures on healthcare utilization, socioeconomic status, return to work, and physical and psychological rehabilitation services. Physiotherapists play a crucial and growing role in the multidisciplinary approach to recovery for post ICU patients, and contributions from clinicians in clinical practice, education, and research will prove a vital component of improving health-related quality of life and functional outcome in survivors of critical illness.

Keywords

Intensive care; Rehabilitation; Outcomes

Funding acknowledgements

Michelle Kho holds a Canada Research Chair in Critical Care Rehabilitation and Knowledge Translation from the Canadian Institutes of Health Research.

Bronwen Connolly received funding from the Guy's & St.Thomas' NHS Foundation Trust and King's College London National Institute of Health Research Biomedical Research Centre to undertake her doctorate.

Relevance to WCPT and expected audience

Recent research supports the role of early physiotherapy to improve outcomes in patients with critical illness. Survivors of critical illness face important challenges in recovery throughout the continuum of care, and physiotherapists play a critical role in the rehabilitation of these survivors from the acute care to community settings. This session will be of interest to clinicians, researchers, educators, and decision-makers.

Target audience

Clinicians, researchers, educators, decision-makers.