Neuromuscular weakness and impairments in physical functioning acquired during critical illness are important components of post-intensive care syndrome (PICS).(1-5) Early rehabilitation and mobilization are safe and reduce the physical complications of critical illness.(6-11) The term early refers to rehabilitation and mobilization activities that begin immediately after stabilization of physiologic derangements, often before patients are liberated from mechanical ventilation and low-dose vasopressor infusions. However, several potential barriers can impede implementation of an early rehabilitation program in the intensive care unit (ICU). A multidisciplinary change in ICU culture to support early rehabilitation, accompanied by selected resources, is essential to overcoming these barriers.(12-14)
Safety of Early Rehabilitation
The safety of early rehabilitation and mobilization in the ICU has been reported in several controlled trials and in studies of routine clinical care in the ICU.(15,16) In two systematic reviews, including 12 studies evaluating early rehabilitation in critically ill patients, the most commonly cited safety event was transient oxygen desaturation; no events impacted patient survival.(15,16)
In one trial, 330 mechanically ventilated patients were assigned to either usual care or early rehabilitation with an ICU mobility team composed of a physical therapist, ICU nurse and nursing assistant.(6) Of the patients assigned to usual care, 47% had at least one physical therapy session during their hospital stay versus 80% of patients assigned to the mobility group. No near-deaths or deaths occurred in either group. In another randomized trial including 104 mechanically ventilated medical ICU (MICU) patients assigned to early physical and occupational therapy versus the usual care group, adverse events occurred in only 0.2% of sessions.(8)
Several studies have verified the safety of early rehabilitation in patients with central venous and arterial catheters.(17) An analysis of 49 mechanically ventilated MICU patients found that only one arterial and no central venous catheters were accidentally removed during early rehabilitation.(9) A prospective evaluation of 101 mechanically ventilated patients with femoral catheters in the Johns Hopkins MICU revealed no femoral catheter-related events during physical therapy sessions that ranged from in-bed exercises to standing and walking.(18) Moreover, no femoral arterial catheter-related adverse events were attributed to participation in rehabilitation in a retrospective case series of 30 cardiovascular ICU patients undergoing 156 activity events.(19)
The physiologic changes commonly associated with early rehabilitation include small variations in heart rate, blood pressure and oxygen saturation.(20,21) Nonetheless, to safely engage patients in early rehabilitation, most studies and clinical programs screen for cardiopulmonary instability and other safety precautions before initiating rehabilitation sessions.(14) Clinical judgment is essential to identifying patients appropriate for active mobilization.
Benefits of Early Rehabilitation
Muscle Strength, Functional Mobility and Quality of Life
Early rehabilitation in the ICU is associated with improved muscle strength, physical function and quality of life.(8,11,15,16,22-28) A randomized trial found that, compared to usual care, early physical and occupational therapies were associated with a greater likelihood of achieving independent functional status, less ICU-acquired weakness, and a greater unassisted walking distance at hospital discharge.(8) A prospective quality improvement project, including implementation of a multidisciplinary team to improve sedation and rehabilitation strategies in the Johns Hopkins MICU, resulted in improved functional mobility in patients undergoing rehabilitation.28 In another randomized trial, ICU-based rehabilitation via cycle ergometry was associated with improved physical function and quality of life.(11)
Length of Stay, Duration of Mechanical Ventilation and Cost Savings
Early rehabilitation may be associated with cost reduction through decreased hospital and/or ICU length of stay (LOS), hospital readmissions and duration of mechanical ventilation.(8,15,16,29) The previously mentioned quality improvement project found an association between early rehabilitation and a decrease in ICU and hospital LOS.(28) Early physical and occupational therapy was also associated with a decrease in ICU LOS and mechanical ventilation in a randomized trial.(8) Similarly, a controlled trial of 330 acute respiratory failure patients demonstrated an association between protocol-driven rehabilitation and a decrease in adjusted ICU and hospital LOS.(6) A subsequent analysis of survivors at one year revealed patients in the usual care group had higher odds of readmission or death than the early mobility group.(30)
In that controlled trial, the average cost per patient in the mobility group was $41,142 compared with $44,302 in the usual care group.(6) The mobility group also had lower absolute costs ($6.8 million vs. $7.3 million). Finally, a financial model, based upon data from the early rehabilitation program in the Johns Hopkins MICU and from existing publications, predicted net financial savings in 83% of possible scenarios when initiating a rehabilitation program.(31) Overall, estimates ranged from $88,000 (net cost) to $3.8 million (net savings).
Potential Barriers to Implementation of Early Rehabilitation in the ICU
Deep sedation, inadequate ICU staffing and gaps in knowledge are potential barriers to early rehabilitation.(13,27,32,33) Reducing or eliminating sedation in the ICU is associated with a shorter time to the first rehabilitation session as well as increased ambulation.(27,33) Findings from a pilot study in the Johns Hopkins MICU emphasized the importance of adequate staffing for successful implementation of early rehabilitation. In this study, therapy was not provided for approximately 50% of ICU days per patient due to limited staffing.(21) ICU physicians and nurses may not entirely realize the long-term impairments associated with immobilization or the safety, feasibility and benefits of early rehabilitation.(9,13) Hence, a professional approach to early rehabilitation, including effective leadership, education and the use of protocols to limit sedation and assess patient appropriateness for mobilization, may address these concerns.(13,32,34)
Feasibility: ICU Culture Change
A change in ICU culture is paramount to successful implementation of an early rehabilitation program.(13,32) In a pre/post cohort study of 104 patients with respiratory failure, transfer from a traditional ICU to a respiratory ICU, where active mobilization was a priority, resulted in a 2.5-fold increase in the odds of ambulation despite identical staffing in the two ICUs.(27) This finding suggests the respiratory ICU’s focus on rehabilitation played a crucial role in the observed increase in ambulation.(13,27)
Adherence to early rehabilitation programs may be enhanced by the use of protocols.(6) A nurse-driven mobility protocol, evaluated in a pre/post quality improvement project, was associated with an increase in ambulation from 6% to 20%.(35) Similarly, mandatory entry of computerized mobility orders also has been associated with a greater proportion of patients being mobilized.(36)
A professional team, including physical and occupational therapists, rehabilitation technicians, critical care physicians, nurses, nursing assistants, and respiratory therapists, can assist with successful implementation of early rehabilitation in the ICU.(14,25,32)
- A medical director may serve as leader and help advocate for the provision of necessary staffing and equipment.(14,32) This equipment may include portable ventilation (Ambu bag with oxygen supply or a portable ventilator), a wheeled walker and a wheelchair. Custom-made mobility aids as used in the Johns Hopkins MICU and elsewhere (e.g., rolling equipment tower, including a portable ventilator), can reduce staffing needs and assist with the feasibility of early ambulation.(14,35,37,38)
- A cycle ergometer is a stationary cycling device that can be used to passively or actively mobilize limbs in patients who are sedated or nonresponsive.(39-41) A randomized trial of cycle ergometry in the ICU demonstrated improvement in muscle strength, six-minute walk distance and quality of life at hospital discharge, when compared to the intervention control group.(11)
- Neuromuscular electrical stimulation generates passive muscle contraction by directing electrical currents to specified muscle groups via a skin electrode.(14,42) It has been associated with an increase in quadriceps muscle thickness in patients who were on mechanical ventilation longer than two weeks as well as a lower incidence of ICU-acquired weakness compared with standard care.(26,43) Further research is ongoing in this area.(44)
Early rehabilitation in the ICU is safe and associated with several benefits, including improvements in muscle strength, functional mobility and quality of life. An early rehabilitation program may reduce hospital costs via decreased ICU and hospital LOS, a reduced duration of mechanical ventilation, and decreased hospital readmissions. Implementation of an early rehabilitation program is made feasible by engaging a multidisciplinary team to identify and address barriers, such as deep sedation, and to accomplish a meaningful change in ICU culture.
- Herridge MS. Legacy of intensive care unit-acquired weakness. Crit Care Med 2009;37:S457-461.
- Herridge MS, Cheung AM, Tansey CM, Matte-Martyn A, Diaz-Granados N, Al-Saidi F, Cooper AB, Guest CB, Mazer CD, Mehta S, Stewart TE, Barr A, Cook D, Slutsky AS, Canadian Critical Care Trials G. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med 2003;348:683-693.
- Fletcher SN, Kennedy DD, Ghosh IR, Misra VP, Kiff K, Coakley JH, Hinds CJ. Persistent neuromuscular and neurophysiologic abnormalities in long-term survivors of prolonged critical illness. Crit Care Med 2003;31:1012-1016.
- Desai SV, Law TJ, Needham DM. Long-term complications of critical care. Crit Care Med 2011;39:371-379.
- Needham DM, Davidson J, Cohen H, Hopkins RO, Weinert C, Wunsch H, Zawistowski C, Bemis-Dougherty A, Berney SC, Bienvenu OJ, Brady SL, Brodsky MB, Denehy L, Elliott D, Flatley C, Harabin AL, Jones C, Louis D, Meltzer W, Muldoon SR, Palmer JB, Perme C, Robinson M, Schmidt DM, Scruth E, Spill GR, Storey CP, Render M, Votto J, Harvey MA. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Crit Care Med 2012;40:502-509.
- Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, Ross A, Anderson L, Baker S, Sanchez M, Penley L, Howard A, Dixon L, Leach S, Small R, Hite RD, Haponik E. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008;36:2238-2243.
- Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriquez L, Hopkins RO. Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007;35:139-145.
- Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman A, Barr R, McCallister KE, Hall JB, Kress JP. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009;373:1874-1882.
- Pohlman MC, Schweickert WD, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman A, Barr R, McCallister K, Hall JB, Kress JP. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med 2010;38:2089-2094.
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- Burtin C, Clerckx B, Robbeets C, Ferdinande P, Langer D, Troosters T, Hermans G, Decramer M, Gosselink R. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med 2009;37:2499-2505.
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