ICU Rehabilitation –h h i h i ’ iThe Physiotherapist’s Perspective

Michelle E. Kho, PT, PhD, ,Assistant ProfessorDepartment of Physical Medicine and Rehabilitation

h ll kh h dmichelle.kho@jhmi.edu

November 16, 2011

Acknowledgements• Co‐investigators

– Alexander Truong, MD, MPHDale Needham MD PhD– Dale Needham, MD, PhD

• Study team– Blinded outcomes assessments – Jen Zanni, MSPT DSc;Blinded outcomes assessments  Jen Zanni, MSPT DSc; 

Julie Skrzat, DPT; Nicole Yare, DPT; Jenna Bohrer, DPT– Research treatments ‐ Nancy Ciesla, DPT, MS; Karen 

Oakjones RN; Dorianne Feldman MD MSPTOakjones, RN; Dorianne Feldman, MD, MSPT

• Salary support (Kho)– Canadian Institutes of Health Research Fellowship and p

Bisby Prize• Grant # UL1 RR 025005 from the National Center for 

Research Resources National Institutes of HealthResearch Resources, National Institutes of Health

• CareRehab, McLean VA

Why is early rehabilitation in the ICU important?important?

• By 2026, the anticipated need for mechanical il i ill i b 80%ventilation will increase by 80%

• Long‐term physical disability (6 minute walk) persists Crit Care Med. 2005;33(3):574‐579.

for up to 5 years post‐ICU

• Lower levels of physical fitness are directly 

NEJM. 2011;364:1293‐304.

p y yassociated with all‐cause mortality and cardiovascular disease JAMA. 1989;262(17):2395‐2401.

• PT & OT often under‐prescribed in the ICU

• Early rehab can reduce ICU and hospital LOSJournal of Critical Care. 2010; 25(2):254‐62.  JCC. 2007; 22:275‐284.

• Early rehab can reduce ICU and hospital LOSArch Phys Med Rehabil 2010;91:536‐42.

Prospective 1‐ and 5‐year follow‐up study of 109 ICU survivors

Setting: 4 Canadian ICUs

ICU ICU

Setting: 4 Canadian ICUsPopulation: Adult patients with ARDS

Outcomes:

Cli i l

DischargeAdmission Primary – 6 minute walk testPulmonary function testsHealth‐related quality of life

Clinical Course

3 months 6 months 12 months 60 months

N=83 N=836 minute walk N=82 N=64N 83281 m49% predicted

N 83422 m66% predicted

6 minute walk distance

N 82396 m64% predicted

N 64436 m76% predicted

RCT of cycling in the ICUC it C M d 2009 37(9) 2499 2505

Primary outcome6 i t lk di t @

Crit Care Med. 2009. 37(9): 2499‐2505.

6 minute walk distance @ hospital discharge (∆=50 m)

Treatment (5d/wk)• Cycling OD  20 min•Respiratory PT•A/PROM U+L/E

196 m [126‐329m]•A/PROM U+L/E•Ambulation as appropriateN=45R p<0.05 

Control (5d/wk)•Respiratory PTA/PROM U+L/E

N=90

143 m [37‐226m]•A/PROM U+L/E•Ambulation as appropriateN=45

143 m [37 226m]

RCT of early PT/OT in the ICU

P i O tPrimary Outcome:Independent functional status @ hospital discharge (FIM + independent walking)

Daily interruption of sedation + Early OT/PT 7d/wk

Medical ICU

59% (29/49) 

ROT/PT  7d/wk

N=49

( / )

p=0.02 

Daily interruption of sedation + Standard care OT/PT

N=104 35% (19/55) OT/PT

N=55

It’s about receiving therapy while on mechanical ventilationon mechanical ventilation

Intervention

•PROM Intervention Control

•AAROM•AROM•Bed

N=49 N=55

Median time to start therapy (d)

1.5 [1.0 to 2.1]* 7.4 [6.0 to 10.9]

•Bed Mobility

•Transfers (sitting)

Median duration of therapy

During MV (h/d) 0.32 [0.17 to 0.48]* 0 [0 to 0]

During no MV (h/d) 0.21 [0.08 to 0.33] 0.19 [0 to 0.38]( g)

•Sitting balance

•ADLs

*= p<0.0001

h/d i•Transfers (standing)

•Ambulation

0.32 h/d = 19.2 minutes

But not all patients can participate in l h bearly rehab

Neuromuscular electrical stimulation is a potential solution

Research QuestionResearch Question

In mechanically ventilated adult ICU patients,Clinicaltrials.gov # NCT00709124

In mechanically ventilated adult ICU patients, does twice‐daily NMES therapy applied bilaterally to lower extremity muscle groupsbilaterally to lower extremity muscle groups compared to sham therapy reduce muscle weakness at hospital discharge?p g

Quadriceps Tibialis Anterior Gastrocnemius

Outcome Measurement Timing

ICU Discharge

Hospital Discharge

ICU Admission

Study Entry >24h MV

Clinical C

g g

NMES/Sham TherapyRoutine PT

Awake

1 Day MV

Course

Test #2 Test #3

Study Outcome Assessments

Test #1

N=82 maximum N=54 maximum (27 per group)

N 19 N 15

Sample Size CalculationEnrollment N=19 N=15Enrollment (as of 11/16/2011)

Success factors for early ICU rehabSuccess factors for early ICU rehab

• Team work

• Coordination

• CommunicationCommunication