Page 261 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 24: Physical Therapy 165

deeply sedated during 58% of all patient-days and were either deeply bias, and the need for patient tolerance reporting will likely yield further
sedated or delirious on more than 85% of all patient-days. As a result, investigation.
only 24% of patients had consultations for PT or OT while in the MICU. Differences in patient selection, application to heterogeneous popula-
Their interventions included education on sedation and mobilization tions, and variable study methodology have all probably contributed to
practices, augmentation of therapist staffing, promotion of physiatry discrepancies in reported outcomes. Notably, the application and titra-
and neurology consultation, and provision of regular feedback to clini- tion of dosing must be reproducible. Electrolyte changes and edema may
cians on these practices. In the post-intervention period, patients were seriously affect conductivity and thus electrical current diffusion, which
less sedated, less delirious, received more therapy services, and exhibited could lessen the intervention’s effect.
improved functional mobility. Additionally, administrative data on all Finally, one novel approach combines the modalities: functional
MICU patients demonstrated reductions in lengths of stay in the ICU electrical stimulation (FES), which augments a motor activity—such
(2.1 days) and hospital (3.1 days). as cycling—with NMES. Muscles are stimulated in functional patterns
similar to normal contraction under volitional control in healthy
ASSISTIVE TECHNOLOGIES individuals. For FES, the majority of the literature to date has been
developed within the chronic stroke and spinal cord injury (SCI)
There is growing interest in the use of assistive technologies to enable populations. Cycling-based FES has been demonstrated to improve
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more patients to commence physical therapy early in an ICU admis- the duration of muscle contraction before reaching the point of fatigue.
sion. Two techniques have shown the greatest promise to date: cycle This may enable patients to train for a longer period of time, thereby
ergometry and electrical stimulation of muscles. Each of these therapies enhancing the training effect.
has broad appeal given both the ability for muscular engagement in the
noninteractive patient and for the potential for nontherapists to enact PRACTICAL IMPLEMENTATION OF AN EXERCISE
therapist-prescribed regimens. This latter feature may help leverage AND MOBILIZATION PROGRAM IN AN ACUTE CARE ICU
scarce experts more effectively.
A cycle ergometer is a stationary cycle with an automatic mechanism ICU rehabilitation has traditionally been better organized in RICUs,
that can alter the amount of work performed by the patient. The cycle weaning centers, and long-term acute care hospitals. In general, patients
can be positioned above the foot of the bed and used passively; engaged in these environments often have attained convalescence from the acute
patients actively pedal with varying resistance. Cycle ergometry has been phase of illness and require less sedation. Accordingly, physical therapy
tested in healthy subjects as part of the space research program and has consultation on all patients is expected and therapy staff is robust. To
been found to preserve thigh muscle thickness during prolonged immo- translate early exercise and mobilization to the acute care ICU, programs
bilization. The method has also been shown to be safe and feasible in must have (1) a clearly defined strategy for managing patient pain, agita-
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studies during hemodialysis and in patients with chronic obstructive tion, and delirium, (2) safety criteria for PT consultation, (3) standard-
pulmonary disease. 51,52 ized PT management schemes, and (4) metrics for PT performance.
Cycle ergometer–based mobilization in addition to standard physical To achieve the benefits of early exercise and mobilization, the patient
therapy care has now been tested as a multimodality form of early mobi- should be as engaged as possible and tethered to the fewest devices
lization in a single-center randomized trial. In this study of 90 patients as is possible. As a result, protocols to guide sedation minimization
with prolonged ICU stays (enrollment began after ICU day 5), patients and early recognition of readiness for extubation are essential. Most
were randomized to early exercise using a bedside cycle ergometer in ICUs implementing early exercise and mobilization programs should
addition to standard PT versus PT alone. Intervention patients under- consider establishing these at the onset. Hallmarks of successful seda-
53
went cycling sessions conducted 5 days per week. At hospital discharge, tion programs include the utilization of a reproducible, validated scale
intervention patients exhibited a longer 6-minute walk distance, higher (eg, Richmond Agitation and Sedation Scale), an established seda-
57
survey scores on physical function, and greater quadriceps force. In tion target prescribed daily, nurse-led titration of drug administration,
addition, the mobilization method was reported to be safe and feasible, and/or the incorporation of daily interruption of continuous sedative
with a median of four cycle sessions completed per week and the time infusions. Similarly, a respiratory therapy–driven protocol to guide
42
taken from ergometer setup to clean up reported at 30 to 40 minutes. assessment of readiness testing, weaning, and extubation has proven
Patients tolerated the 425 cycling sessions well without serious adverse benefit, and pairing this with sedation interruption has yielded demon-
events; only 4% of sessions had early termination due to oxygen desatu- strable improvements. 3
ration and blood pressure changes. Appropriate consultation practices are necessary in an environment
Neuromuscular electrical stimulation (NMES) creates nonvolitional of limited physical therapy resources. We advocate for criteria focus-
(passive) contraction of skeletal muscles. Low-voltage electrical impulses ing on the cardiovascular, pulmonary, and neurological systems to help
are delivered from the skin surface electrodes to underlying muscle. nontherapy clinicians identify ICU patients who are appropriate for
Accordingly, the modality is also known as transcutaneous electrical PT consultation. These criteria, in accordance with prior literature on
muscle stimulation (TEMS). NMES is used commonly in both in- and mobilization of patients undergoing MV, may develop further as experi-
outpatient rehabilitation settings to preserve or improve muscle mass, ence with acute care therapy services mature. Furthermore, evidence
strength, and function and has been studied most extensively in patients has shown that exercise and mobilization can be conducted in contexts
with chronic heart failure and those with chronic obstructive pulmonary of greater ventilator dependence. We advocate further liberalization of
disease. In a recent systematic review, NMES was found to improve the oxygenation criterion based on institutional experience and comfort.
muscle strength, exercise capacity, and disease-specific health status. 54 Finally, the criteria are purposefully “lean” and may not be restrictive
Despite the promise of TEMS, randomized controlled trials in critical enough for general practice (eg, gastrointestinal bleeding). Future stud-
illness have reported conflicting results. Six unique ICU trials in patients ies to validate these criteria are needed.
with acute respiratory failure and sepsis and a trial in patients receiving In contrast, patient engagement may not be necessary in programs
chronic MV demonstrated mixed, but promising results for the potential developing more cycle ergometry and TEMS programs. Interestingly,
efficacy. The largest study to date investigated 140 critically ill patients passive ROM exercises in the comatose patient may be best performed
55
randomly assigned to TEMS versus standard care. TEMS was conducted by nontherapist clinicians (eg, nurse, nurse assistants) and potentially
daily for 55 minutes to the lower limb (vastus lateralis, vastus medialis, augmented by patient family members.
and peroneus longus muscles). Patients in the intervention arm exhib- Once patients have been deemed ready to begin mobilization, it
ited higher Medical Research Council scores compared with controls should proceed in a logical, stepwise fashion. Activity and exercise should
(58 vs 52). However, concerns over endpoint selection, measurement be targeted at the appropriate intensity and with the appropriate

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