Facilitating Early Mobilization through Technology in Critically Ill Patients

2016 - 1 February - Technological Game Changers
Karen Choong, MB, BCh, MSc
An expert outlines technological advances designed to promote early mobility in patients.

 

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.

References:

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