Mobility-based physical therapy has multiple physical, neurocognitive and quality-of-life benefits,(1) such that early mobilization is now recommended as a practice priority in adult intensive care units (ICUs).(2,3) To support this, technologies have been adapted to the critical care setting to maintain range of motion and mobility, prevent muscle wasting and enhance functional recovery. Here are some of the technologies currently being evaluated in this population.
Cycle ergometry. In-bed, supine cycling is currently used in critically ill adults and children who have difficulty mobilizing out of bed. It can be applied to promote passive or active exercise in patients who are either awake or sedated. While there are several models that have been used in adults (RT300 Supine, Restorative Therapies; MOTOmed letto 2, RECK; and Flexmotor, Cajumoro), only the RT300 Supine is currently adapted for pediatric use. It has the ability to set and monitor the degree of active cycling, speed, duration, distance and power generated over each session. It also benefits from an interactive component on a portable tablet (Figure 1). The challenge for pediatrics is size. The lowest age for the RT300 is approximately four years. One size does not fit all; cycling arms, pedals and calf supports must be adjusted according to the patient’s size. A single-center randomized trial in ill adults suggests that cycle-ergometer-based mobilization improves functional outcomes,(4) and further trials are underway.(5,6) Safety and feasibility of in-bed cycling has been demonstrated in children,(7) and a pilot randomized trial of cycle ergometry as an adjunct to usual care physiotherapy is in progress.(8)
Interactive virtual reality exercise. Virtual rehabilitation and the use of video game technology in the field of medical and assistive applications is rapidly advancing. Our experience with Microsoft’s Kinect for Xbox 360 and Leap Motion is that the motion controller and sensor have difficulty discriminating between the patient and the background of the bed. Also, this technology is unfortunately limited in supine, bed-ridden, critically ill patients because active participation is a prerequisite. Nevertheless, the safety and feasibility of the Nintendo Wii has been demonstrated in critically ill adults and children, where it has been used to enhance upper limb mobility, as well as balance and endurance.(9,10) We found that virtual rehabilitation is feasible in only a minority of pediatric ICU patients who are cognitively able, and awake enough, to comply.(7) By the time that video games can be applied, these patients are practically ready for ICU discharge.(7)
Electrical stimulation therapy. Therapies such as neuromuscular and functional electrical stimulation (NMES and FES) use pulsed currents to stimulate motor nerves, which in turn produce muscle contraction. NMES stimulates passive contraction of isolated muscle groups in nonfunctional resting positions, and has been proposed as a method of enhancing nonvolitional muscle contraction. FES recruits several muscles concurrently in functional patterns that mimic volitional muscle contraction, and has primarily been used in the rehabilitation of patients with spinal cord injury or cerebral palsy.(11,12) There is some suggestion that this technology is safe, and may improve muscle strength in adults,(13,14) However, the heterogeneity in studies with respect to timing, duration of treatment and protocols, together with the lack of functional outcomes data, does not allow us to draw any conclusions regarding its efficacy.(15) It has yet to be studied in critically ill children.
Specialty beds and transfer aids. There are a variety of specialty beds and hydraulic assist platforms available to support in-bed resistance training, transfers, and progressive pre-ambulation training in adults.(16) Custom-made aids have been specifically designed to enable the safe mobilization of critically ill patients while they remain attached to their invasive devices, thus allowing the rehabilitation team to focus on aspects of the patient’s therapy and physiologic response during exercise. Examples include the MOVER Aid,(17) and a cannula-support device to facilitate rehabilitation in a child on extracorporeal membrane oxygenation.(18) Beds that provide kinetic therapy, the rotation of a patient along the longitudinal axis of 40 degrees or more to each side continuously, has the proposed benefits of automatic position changes and percussion chest physiotherapy, which in turn may enhance lung recruitment and reduce the risk of ventilator-associated pneumonia.(19) Pilot pediatric data suggests that kinetic therapy is more efficient than standard therapy in improving short-term oxygenation;(20) however, this technology has not been widely studied, and there is no clear evidence of efficacy on patient outcomes.(19)
Whole Body Periodic Acceleration. This refers to the motion of the supine body in the head-to-foot (z) axis in a sinusoidal fashion using a motion platform, at a frequency range of 100–160 cycles/min. It is proposed as a form of passive exercise, for which the mechanism of action is through the release of nitric oxide from vascular endothelial pulsatile shear stress. This in turn reduces inflammation and promotes flow-mediated vasodilation in the cardiovascular and cerebral circulations.(21,22) Clinical human research is very much in its infancy, and its applicability in the critical setting is unknown. However, this technology is attractive for its noninvasiveness, and may overcome some of the limitations of movement in bedridden patients with disabilities and restricted reserve, mobility and size, for whom other technologies cannot be applied.
None of the currently available technologies can replace the physical assessment and expertise of a rehabilitation specialist who can not only prescribe an individualized rehabilitation plan, but can obtain feedback on patient response, monitor progress over time and interact as the patient’s coach and personal trainer. Hence, none of these technologies should be applied without the guidance of experts, Furthermore, patients need to be motivated; children in particular need significant encouragement and imaginative ways to keep them interested in mobility activities. Family engagement is a key influence on a child’s motivation.(23) Mobilization of critically ill patients is labor intensive, and the majority of institutions have limited resources to facilitate mobilization in mechanically ventilated patients.(24) While advancement in technologies will no doubt play an important role, we have a responsibility to evaluate how best to use this technology within evidence-based mobilization protocols and how to complement technology with the ICU Liberation bundle.
1. Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med. 2013 Jun;41(6):1543-1554.
2. Calvo-Ayala E, Khan BA, Farber MO, Ely EW, Boustani MA. Interventions to improve the physical function of ICU survivors: a systematic review. Chest. 2013 Nov;144(5):1469-1480.
3. Hodgson CL, Stiller K, Needham DM, et al. Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Crit Care. 2014 Dec 4;18(6):658.
4. Burtin C, Clerckx B, Robbeets C, et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med. 2009 Sep;37(9):2499-2505.
5. Kho ME. CYCLE Pilot Randomized Trial. ClinicalTrials.gov Identifier: NCT02377830. Last verified 2016.
6. dos Santos LJ, de Aguiar Lemos F, Bianchi T, et al. Early rehabilitation using a passive cycle ergometer on muscle morphology in mechanically ventilated critically ill patients in the intensive care unit (MoVe-ICU study): study protocol for a randomized controlled trial. Trials. 2015 Aug 28;16:383.
7. Choong K, Chacon MDP, Walker RG, et al. In-bed mobilization in critically ill children: a safety and feasibility trial. J Pediatr Intensive Care. 2015;04(04):225-234.
8. Choong K. Early In-bed Cycling in Critically Ill Children (wEECycle). Clinicaltrials.gov Identifier: NCT02358577. Last verified November 2015.
9. Abdulsatar F, Walker RG, Timmons BW, Choong K. "Wii-Hab" in critically ill children: a pilot trial. J Pediatr Rehabil Med. 2013 Jan 1;6(4):193-204.
10. Kho ME, Damluji A, Zanni JM, Needham DM. Feasibility and observed safety of interactive video games for physical rehabilitation in the intensive care unit: a case series. J Crit Care. 2012 Apr;27(2):219.e1-219.e6.
11. Mayson TA, Harris SR. Functional electrical stimulation cycling in youth with spinal cord injury: a review of intervention studies. J Spinal Cord Med. 2014 May;37(3):266-277.
12. Chiu HC, Ada L. Effect of functional electrical stimulation on activity in children with cerebral palsy: a systematic review. Pediatr Phys Ther. 2014 Fall;26(3):283-288.
13. Dirks ML, Hansen D, Van Assche A, Dendale P, Van Loon LJ. Neuromuscular electrical stimulation prevents muscle wasting in critically ill comatose patients. Clin Sci (Lond). 2015 Mar;128(6):357-365.
14. Parry SM, Berney S, Warrillow S, et al. Functional electrical stimulation with cycling in the critically ill: a pilot case-matched control study. J Crit Care. 2014 Aug;29(4):695.e1-695.e7.
15. Williams N, Flynn M. A review of the efficacy of neuromuscular electrical stimulation in critically ill patients. Physiother Theory Pract. 2014 Jan;30(1):6-11.
16. Trees DW, Smith JM, Hockert S. Innovative mobility strategies for the patient with intensive care unit-acquired weakness: a case report. Phys Ther. 2013 Feb;93(2):237-247.
17. Needham DM, Truong AD, Fan E. Technology to enhance physical rehabilitation of critically ill patients. Crit Care Med. 2009 Oct;37(10 Suppl):S436-S441.
18. Zebuhr C, Sinha A, Skillman H, Buckvold S. Active rehabilitation in a pediatric extracorporeal membrane oxygenation patient. PM R. 2014 May;6(5):456-460.
19. Delaney A, Gray H, Laupland KB, Zuege DJ. Kinetic bed therapy to prevent nosocomial pneumonia in mechanically ventilated patients: a systematic review and meta-analysis. Crit Care. 2006;10(3):R70.
20. Schultz TR, Lin R, Francis BA, et al. Kinetic therapy improves oxygenation in critically ill pediatric patients. Pediatr Crit Care Med. 2005 Jul;6(4):428-434; quiz 440.
21. Sakaguchi M, Fukuda S, Shimada K, et al. Preliminary observations of passive exercise using whole body periodic acceleration on coronary microcirculation and glucose tolerance in patients with type 2 diabetes. J Cardiol. 2012 Oct;60(4):283-287.
22. Adams JA, Uryash A, Bassuk J, Sackner MA, Kurlansky P. Biological basis of neuroprotection and neurotherapeutic effects of whole body periodic acceleration (pGz). Med Hypotheses. 2014 Jun;82(6):681-687.
23. Karver MS, Handelsman JB, Fields S, Bickman L. Meta-analysis of therapeutic relationship variables in youth and family therapy: the evidence for different relationship variables in the child and adolescent treatment outcome literature. Clin Psychol Rev. 2006 Jan;26(1):50-65.
24. Balas MC, Burke WJ, Gannon D, et al. Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines. Crit Care Med. 2013 Sep;41(9 Suppl 1):S116-S127.