Intensifying physical rehab in the ICU has no apparent benefit

Last Updated: 2017-08-31

By Scott Baltic

NEW YORK (Reuters Health) - Increasing the intensity and frequency of physical rehabilitation for ICU patients did not appear to improve physical outcomes 6 months later, UK-based researchers report.

The authors conclude that their findings "raise important questions about how early rehabilitation should be optimally delivered in the critically ill."

Prior research had shown that early physical and occupational therapy in mechanically ventilated ICU patients is well tolerated and yields better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days, compared with standard care.

For their randomized trial, the researchers recruited 308 people who had received at least 48 hours of mechanical ventilation at general ICUs in England. The report was published in Thorax, online August 5.

Corresponding author Dr. Simon Baudouin of the Royal Victoria Infirmary, Newcastle upon Tyne, told Reuters Health by email that most participants had emergency admissions, with about equal numbers from the medical and surgical populations. Individual diagnoses were not collected, but the patients typically had common ICU conditions such as septic shock, pneumonia, and bowel perforation.

"These were very ill patients, as demonstrated by their APACHE II (severity of illness) admission scores, with high predicted mortality," he said.

Participants were randomized to receive, Monday through Friday, either standard physical rehabilitation (30 minutes per day) or intensive rehab (90 minutes daily split into at least two sessions). In both groups, functional training and individually tailored exercise programs were provided by experienced critical-care physiotherapists.

In the end, patients received a mean of only 23 minutes and 13 minutes of physical therapy per treatment day in the intervention and standard-care groups, respectively. The main obstacles to more rehab in the intensive group were "difficulty in achieving optimum levels of sedation (to allow rehabilitation to proceed safely) and participant fatigue," the authors write, as well as an inability to provide rehab on weekends.

Many of the participants died or were lost to follow-up within 6 months. Six-month data were available for 116 patients: 54 standard-care and 62 intervention recipients.

At 6 months, the two groups did not differ significantly in the primary outcome - self-reported physical health - or in secondary outcomes, which included functional ability and independence, length of ICU and hospital stay, and mortality.

The researchers write that "the absolute difference in the amount of physical rehabilitation received by participants in each arm of the trial was smaller than anticipated and possibly insufficient to produce a measurable difference in outcome."

A main challenge in physical therapy is identifying the optimal dose-response ratio, Dr. Jim Smith, professor of physical therapy at Utica College, in New York State, told Reuters Health by phone. Although this study was designed "extremely well," he added, "this doesn't tell me much about the intensity I need to use with my patients."

Dr. Smith, a past president of the Academy of Acute Care Physical Therapy, was not involved with the study.

Smith also is bothered by the lack of physical therapy on weekends: "If it's important, it's important 7 days a week." Still, he sees potentially good news in the possibility that a shorter duration of physical rehab may suffice for most patients.

Guidelines from the Society of Critical Care Medicine, Smith noted, recommend early mobilization to prevent delirium, bone demineralization, and other consequences of time in an ICU, such as post-intensive care syndrome and a low return-to-work rate.

Until more recently, he said, the common practice had been to put ICU patients under heavy sedation to minimize pain, but that often led to delirium, which was associated with a risk of post-traumatic stress disorder down the road.

The trend now is for lighter sedation, Smith said. "We want to get them upright, active and engaged with us."

SOURCE: http://bit.ly/2vqVpzw

Thorax 2017.