Physical Therapy

Craik, Rebecca L.

doi: 10.2522/ptj.2012.92.12.1482pmid: 23204509

Ohtake, Patricia J.; Strasser, Dale C.; Needham, Dale M.

doi: 10.2522/ptj.2012.92.12.1484pmid: 23204510

Harabin, Andrea L.; Kiley, James P.

doi: 10.2522/ptj.20110436pmid: 22836006

This report provides a brief overview of some relevant ongoing research on critical care and how research priorities are determined by the National Heart, Lung, and Blood Institute. Long-term and patient-centered outcomes have become more prominent research questions for clinical studies in patients who are critically ill. Rehabilitation research would be appropriate in this context, and funding is most likely received through investigator-initiated R01 applications. National Institutes of Health program staff are available for discussion and advice and encourage contact from extramural investigators.

Nordon-Craft, Amy; Moss, Marc; Quan, Dianna; Schenkman, Margaret

doi: 10.2522/ptj.20110117pmid: 22282769

Patients admitted to the intensive care unit (ICU) can develop a condition referred to as “ICU-acquired weakness.” This condition is characterized by profound weakness that is greater than might be expected to result from prolonged bed rest. Intensive care unit–acquired weakness often is accompanied by dysfunction of multiple organ systems. Individuals with ICU-acquired weakness typically have significant activity limitations, often requiring physical assistance for even the most basic activities associated with bed mobility. Many of these individuals have activity limitations months to years after hospitalization. The purpose of this article is to review evidence that guides physical rehabilitation of people with ICU-acquired weakness. Included are diagnostic criteria, medical management, and prognostic indicators, as well as criteria for beginning physical rehabilitation, with an emphasis on patient safety. Data are presented indicating that rehabilitation can be implemented with very few adverse effects. Evidence is provided for appropriate measurement approaches and for physical intervention strategies. Finally, some of the key issues are summarized that should be investigated to determine the best intervention guidelines for individuals with ICU-acquired weakness.

Denehy, Linda; Berney, Sue; Whitburn, Laura; Edbrooke, Lara

doi: 10.2522/ptj.20110411pmid: 22577066

BackgroundPromotion of increased physical activity is advocated for survivors of an intensive care unit (ICU) admission to improve physical function and health-related quality of life.ObjectiveThe primary aims of this study were: (1) to measure free-living physical activity levels and (2) to correlate the measurements with scores on a self-reported activity questionnaire. A secondary aim was to explore factors associated with physical activity levels.DesignThis was a prospective cohort study.MethodsNested within a larger randomized controlled trial, participants were block randomized to measure free-living physical activity levels. Included participants wore an accelerometer for 7 days during waking hours at 2 months after ICU discharge. At completion of the 7 days of monitoring, participants were interviewed using the Physical Activity Scale for the Elderly (PASE) questionnaire. Factors associated with physical activity were explored using regression analysis.ResultsThe ICU survivors (median age=59 years, interquartile range=49–66; mean Acute Physiologic Chronic Health Evaluation [APACHE II] score=18, interquartile range=16–21) were inactive when quantitatively measured at 2 months after hospital discharge. Participants spent an average of 90% of the time inactive and only 3% of the time walking. Only 37% of the sample spent 30 minutes or more per day in the locomotion category (more than 20 steps in a row). Activity reported using the PASE questionnaire was lower than that reported in adults who were healthy. The PASE scores correlated only fairly with activity measured by steps per day. The presence of comorbidities explained one third of the variance in physical activity levels.LimitationsAccelerometer overreading, patient heterogeneity, selection bias, and sample size not reached were limitations of the study.ConclusionsSurvivors of an ICU admission greater than 5 days demonstrated high levels of inactivity for prolonged periods at 2 months after ICU discharge, and the majority did not meet international recommendations regarding physical activity. Comorbidity appears to be a promising factor associated with activity levels.

Hopkins, Ramona O.; Miller, Russell R.; Rodriguez, Larissa; Spuhler, Vicki; Thomsen, George E.

doi: 10.2522/ptj.20110446pmid: 22491481

BackgroundWeakness and debilitation are common following critical illness. Studies that assess whether early physical activity initiated in the intensive care unit (ICU) continues after a patient is transferred to a ward are lacking.ObjectiveThe purpose of this study was to assess whether physical activity and mobility initiated during ICU treatment were maintained after patients were discharged from a single ICU to a ward.DesignThis was a cohort study.MethodsConsecutive patients who were diagnosed with respiratory failure and admitted to the respiratory ICU (RICU) at LDS Hospital underwent early physical activity and mobility as part of usual care. Medical data, the number of requests for a physical therapy consultation or nursing assistance with ambulation at ICU discharge, and mobility data were collected during the first 2 full days on the ward.ResultsOf the 72 patients who participated in the study, 65 had either a physical therapy consultation or a request for nursing assistance with ambulation at ward transfer. Activity level decreased in 40 participants (55%) on the first full ward day. Of the 61 participants who ambulated 100 ft (30.48 m) or more on the last full RICU day, 14 did not ambulate, 22 ambulated less than 100 ft, and 25 ambulated 100 ft or more on the first ward day.LimitationsLimitations include lack of data regarding why activity was not performed on the ward, lack of longitudinal follow-up to assess effects of activity, and lack of generalizability to patients not transferred to a ward or not treated in an ICU with an early mobility program.ConclusionsDespite the majority of participants having a physical therapy consultation or a request for nursing assistance with ambulation at the time of transfer to the medical ward, physical activity levels decreased in over half of participants on the first full ward day. The data suggest a need for education of ward staff regarding ICU debilitation, enhanced communication among care providers, and focus on the importance of patient-centered outcomes during and following ICU treatment.

Berney, Sue; Haines, Kimberley; Skinner, Elizabeth H.; Denehy, Linda

doi: 10.2522/ptj.20110406pmid: 22879441

BackgroundSurvivors of critical illness can experience long-standing functional limitations that negatively affect their health-related quality of life. To date, no model of rehabilitation has demonstrated sustained improvements in physical function for survivors of critical illness beyond hospital discharge.ObjectiveThe aims of this study were: (1) to describe a model of rehabilitation for survivors of critical illness, (2) to compare the model to local standard care, and (3) to report the safety and feasibility of the program.DesignThis was a cohort study.MethodsAs part of a larger randomized controlled trial, 74 participants were randomly assigned, 5 days following admission to the intensive care unit (ICU), to a protocolized rehabilitation program that commenced in the ICU and continued on the acute care ward and for a further 8 weeks following hospital discharge as an outpatient program. Exercise training was prescribed based on quantitative outcome measures to achieve a physiological training response.ResultsDuring acute hospitalization, 60% of exercise sessions were able to be delivered. The most frequently occurring barriers to exercise were patient safety and patient refusal due to fatigue. Point prevalence data showed patients were mobilized more often and for longer periods compared with standard care. Outpatient classes were poorly attended, with only 41% of the patients completing more than 70% of outpatient classes. No adverse events occurred.LimitationsLimitations included patient heterogeneity and delayed commencement of exercise in the ICU due to issues of consent and recruitment.ConclusionsExercise training that commences in the ICU and continues through to an outpatient program is safe and feasible for survivors of critical illness. Models of care that maximize patient participation across the continuum of care warrant further investigation.

Thrush, Aaron; Rozek, Melanie; Dekerlegand, Jennifer L.

doi: 10.2522/ptj.20110412pmid: 22956427

Background and PurposeLong-term acute care hospitals (LTACHs) have emerged for patients requiring medical care beyond a short stay. Minimal data have been reported on functional outcomes in this setting. The purposes of this study were: (1) to measure the clinical utility of the Functional Status Score for the Intensive Care Unit (FSS-ICU) in an LTACH setting and (2) to explore the association between FSS-ICU score and discharge setting.ParticipantsData were obtained from 101 patients (median age=70 years, interquartile range [IQR]=61–78; 39% female, 61% male) who were admitted to an LTACH. Participants were categorized into 1 of 5 groups by discharge setting: (1) home (n=14), (2) inpatient rehabilitation facility (n=26), (3) skilled nursing facility (n=23), (4) long-term care/hospice/expired (n=13), or (5) transferred to a short-stay hospital (n=25).MethodsData were prospectively collected from a 38-bed LTACH in the United States over 8 months beginning in September 2010. Functional status was scored using the FSS-ICU within 4 days of admission and every 2 weeks until discharge. The FSS-ICU consists of 5 categories: rolling, supine-to-sit transfers, unsupported sitting, sit-to-stand transfers, and ambulation. Each category was rated from 0 to 7, with a maximum cumulative FSS-ICU score of 35.ResultsCumulative FSS-ICU scores significantly improved from a median (IQR) of 9 (3–17) to 14 (5–24) at discharge. Median (IQR) cumulative discharge FSS-ICU scores were significantly different among the discharge categories: home=28 (22–32), inpatient rehabilitation facility=21 (15–24), skilled nursing facility=14 (8–21), long-term care/hospice/expired=5 (0–11), and transfer to a short-stay hospital=4 (0–7).Discussion and ConclusionsPatients receiving therapy at an LTACH demonstrate significant improvements from admission to discharge using the FSS-ICU. This outcome tool discriminates among discharge settings and successfully documents functional improvements of patients in an LTACH setting.

Lee, Jeanette J.; Waak, Karen; Grosse-Sundrup, Martina; Xue, Feifei; Lee, Jarone; Chipman, Daniel; Ryan, Cheryl; Bittner, Edward A.; Schmidt, Ulrich; Eikermann, Matthias

doi: 10.2522/ptj.20110403pmid: 22976446

Alison, Jennifer A.; Kenny, Patricia; King, Madeleine T.; McKinley, Sharon; Aitken, Leanne M.; Leslie, Gavin D.; Elliott, Doug

doi: 10.2522/ptj.20110410pmid: 22577064

BackgroundThe Six-Minute Walk Test (6MWT) is widely used as an outcome measure in exercise rehabilitation. However, the repeatability of the 6MWT performed at home in survivors of a critical illness has not been evaluated.ObjectiveThe purpose of this study was to evaluate, in survivors of a critical illness: (1) the repeatability of the 6MWT performed at home, (2) the effect on estimates of change in functional exercise capacity if only one 6MWT was performed at follow-up assessments, and (3) the relationship between the physical functioning (PF) score of the 36-Item Short-Form Health Survey questionnaire (SF-36) and the 6MWT.DesignRepeated measures of the 6MWT and SF-36 were obtained.MethodsEligible participants had an intensive care unit (ICU) length of stay of ≥48 hours and were mechanically ventilated for ≥24 hours. Two 6MWTs and the SF-36 were conducted in participants' homes at weeks 1, 8, and 26 after hospital discharge.ResultsOne hundred seventy-three participants completed the study. The participants had a mean age of 57 years (SD=16), a mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score on admission of 19 (SD=10), a mean ICU length of stay of 9 days (SD=8), and a mean mechanical ventilation time of 140 hours (SD=137). Of the 173 participants, 110 performed two 6MWTs at weeks 1, 8, and 26. There were significant mean increases in 6-minute walk distance in the second test of 15 m (P<.0001) at week 1, 13 m (P<.0001) at week 8, and 9 m (P=.04) at week 26. If only one 6MWT was performed at weeks 8 and 26, the estimate of change in 6-minute walk distance from week 1 was 19 m less (P<.001) at both weeks 8 and 26. There was a moderate to strong correlation between SF-36 PF score and 6-minute walk distance at each assessment (week 1: r=.62, P<.001; week 8: r=.55, P<.001; and week 26: r=.47, P<.001).LimitationsSome study participants were unable to perform a second 6MWT, and these participants may have differed in important aspects of function compared with those individuals who completed two 6MWTs.ConclusionsIn survivors of a critical illness, the 6MWT in the home environment should be performed twice at each assessment to give an accurate reflection of change in exercise capacity over time. The SF-36 PF score was a strong indicator of 6-minute walk distance in early recovery from a critical illness.