Physiotherapy in intensive care is safe: an observational study

The Association of Conventional Therapy Associated with Somatosensory Interactive Game Enhances the Effects of Early Pulmonary Rehabilitation for Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial

Objective: This study aimed to evaluate the effect of somatosensory interactive games in combination with pulmonary rehabilitation programs (PRPs) on exercise tolerance, balance function, pulmonary function, inflammatory markers, and healthcare utilization in individuals with acute exacerbation of chronic obstructive pulmonary disease over 12 months. Design: In a randomized controlled trial, 80 patients were divided into two groups. The control group participated in a lasted 30 minutes daily program composed of postural training for 10 minutes, limb movement for 10 minutes, and breathing exercises for 10 minutes based on regular oxygen therapy and medication. The experimental group received a once-daily, 20-minute somatosensory interactive game session based on the control group. Patients began treatment within 48 hours after admission and lasted for 6 weeks. Results: The time × group interactions on 6-minute walk distance (6MWD) and Brief Balance Evaluation Systems Test (Brief-BESTest) between the two groups were significant (P < 0.001). At the postintervention and each time point of follow-up, the 6-minute walk distance (6MWD) and Brief-BESTest of the intervention group were significantly higher than those of the control group (P < 0.05). The effects of time factor on forced expiratory volume in one second and forced vital capacity were statistically significant (P < 0.05). The 6MWD and Brief-BESTest of the intervention group peaked 3 months after the intervention and were higher than the control group within 12 months. C-reactive protein and procalcitonin were similar between the groups before and after intervention (P > 0.05). The readmission rates and mean length of time spent in the hospital were comparable between the groups at 12 months (P > 0.05). Conclusions: The addition of somatosensory interactive games based on a PRP was safe and feasible, and this benefit persisted for 12 months, peaked at 3 months after the intervention, and then gradually decreased.

Out-of-the-ICU Mobilization in Critically Ill Patients: The Safety of a New Model of Rehabilitation

Early mobilization of ICU patients has been reported to be safe and feasible. Recently, our ICU implemented out-of-the-ICU wheelchair excursions as a daily rehabilitation practice. The aim of this study is to investigate the safety of participation in the out-of-the-ICU program for early mobilization.

Physiological abnormalities and adverse events during physical therapy in the intensive care unit after cardiac surgery: A prospective observational study

BACKGROUND

After cardiac surgery, physiological abnormalities or adverse events might occur in patients in the intensive care unit (ICU) during physical therapy care. Identifying these events may help improve patient safety and care.

OBJECTIVES

To estimate the incidence and the degree of severity of physiological abnormalities or adverse events during physical therapy interventions provided in the ICU after cardiac surgery. To explore the relationship between these events and patients' characteristics and clinical outcomes.

METHODS

Prospective observational study of adult patients in the postoperative period of cardiac surgery admitted to the ICU of a referenced university hospital. Physical therapy interventions were observed by a team trained to evaluate and register the occurrence of physiological abnormalities or adverse events and grading their consequences. We compared baseline characteristics and outcomes of patients with versus without these events.

RESULTS

We observed 935 physical therapy interventions in 323 patients, of which 189 (20%, 95% confidence interval: 18, 23%) resulted in physiological abnormalities or adverse events. The highest incidences of these events were observed during endotracheal suctioning (44%), walking (40%), and noninvasive ventilation (37%). Hemodynamic changes were the most frequent events accounting for 74% of all events. Only 2% of interventions resulted in mild harm and 0.2% in moderate harm. The presence of comorbidities was associated (p = 0.03) with the occurrence of these events.

CONCLUSION

Physiological abnormalities or adverse events occurred in 20% of physical therapy interventions in patients in the ICU after cardiac surgery, with 10% of those resulting in negative effects. Only the presence of comorbidities was associated with the occurrence of these events.

Efficacy of Respiratory Physiotherapy Interventions for Intubated and Mechanically Ventilated Adults with Pneumonia: A Systematic Review and Meta-Analysis

Purpose: A systematic review was conducted to investigate the effect of respiratory physiotherapy on mortality, quality of life, functional recovery, intensive care length of stay, duration of ventilation, oxygenation, secretion clearance, and pulmonary mechanics for invasively ventilated adults with pneumonia. Method: Five databases were searched for randomized trials published between January 1995 and November 2018. Study quality was assessed using a standardized Joanna Briggs Institute critical appraisal tool, and Review Manager software was used to pool the studies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the level of certainty of the evidence. Results: A total of 14 studies of moderate quality included 251 subjects with pneumonia. Eight studies were pooled for meta-analysis. Interventions that increased inspiratory volume appeared to benefit secretion clearance by nearly 2 grams (mean difference [MD] 1.97; 95% CI: 0.80, 3.14; very low GRADE evidence) and increase static lung compliance immediately after treatment by more than 5 millilitres/centimetre H20 (MD 5.40 mL/cm H2O; 95% CI: 2.37, 8.43; very low GRADE evidence) or by more than 6 millilitres/centimetre H2O after a 20- to 30-minute delay (MD 6.86 mL/cm H2O; 95% CI: 2.86, 10.86; very low GRADE evidence). No adverse events were found. Conclusions: Respiratory physiotherapy that increases tidal volume may benefit secretion clearance and lung compliance in invasively ventilated adults with pneumonia, but its impact on other outcomes, including mortality, length of stay, and other patient-centred outcomes, is unclear, and further research is required.

The safety and efficacy of prolonged use of one-way speaking valves

BACKGROUND

One-way speaking valves were first engineered to improve communication in patients with tracheostomies. More recently, additional indications for one-way speaking valves have been explored, including improving ventilation, weaning, and reducing aspiration; however, safety and adverse events have not been well defined.

OBJECTIVES

The aim of this study was to examine the cardiorespiratory changes that occur with prolonged use of a one-way speaking valve in relation to safety and efficacy.

METHODS

A prospective observational study of adult patients (n = 20) was carried out in a tertiary level intensive care unit. Continuous monitoring of cardiorespiratory parameters, including heart rate (beats per minutes), respiratory rate (breaths per minute), systolic, diastolic, and mean arterial pressure (mmHg), and oxygen saturations (%), was conducted for 2 h whilst participants used a one-way speaking valve. The participants then continued to use the one-way speaking valve as long as tolerated. Data are reported as median and range (non-normative data) or as mean ± standard deviation (normative data).

RESULTS

The time to tracheostomy was 17.5 (range = 7-54) days after the initiation of mechanical ventilation, and the time to first use of the one-way speaking valve was 11.4 days (standard deviation = 5.46) after tracheostomy. The participants tolerated using a one-way speaking valve (for more than 2 h) after a median of 2 (range = 1-8) days from first use. There were no significant changes to any cardiorespiratory parameters over the 2-h period and also no adverse events in this study whilst participants used one-way speaking valves for up to 17 (range = 5.5-17) hours.

CONCLUSIONS

The prolonged use of a one-way speaking valve is safe for patients who reached a threshold of 2 h.

Cambios fisiológicos relacionados con entrenamiento muscular respiratorio en pacientes con ventilación mecánica

Introducción. El entrenamiento muscular respiratorio es una técnica fisioterapéutica usada para incrementar la fuerza de la musculatura respiratoria, sin embargo pocos estudios han abordado los cambios fisiológicos relacionados con esta intervención en pacientes con ventilación mecánica.Objetivo. Determinar los cambios fisiológicos relacionados con el entrenamiento muscular respiratorio en pacientes con ventilación mecánica.Materiales y métodos. Se realizó un análisis de datos secundarios en el marco del estudio “Eficacia del entrenamiento muscular respiratorio en el destete de la ventilación mecánica en pacientes con ventilación mecánica por 48 horas o más: Un ensayo clínico controlado”. La población estuvo conformada por los 62 pacientes del grupo experimental del estudio principal, quienes recibieron entrenamiento muscular respiratorio. Los valores de frecuencia cardiaca, frecuencia respiratoria, presión arterial, saturación de oxígeno y volumen corriente fueron registrados. La diferencia entre el promedio de cada una de las variables fue analizada mediante la prueba de t pareada, mientras que para el análisis de los cambios fisiológicos entre sesiones de entrenamiento se empleó la prueba de Kruskal-Wallis.Resultados. Se observaron diferencias significativas entre las variables fisiológicas antes y después del entrenamiento muscular respiratorio (p<0.05), a excepción del volumen corriente y la presión arterial media (p>0.05). Por el contrario, no se observaron diferencias significativas en ninguna de las variables fisiológicas entre sesiones de entrenamiento (p>0.05)Conclusiones. El entrenamiento muscular respiratorio es una intervención terapéutica viable y tolerable en esta población.

Physiotherapy in the neurotrauma intensive care unit: A scoping review

PURPOSE

This scoping review summarizes the literature on the safety and effectiveness of physiotherapy interventions in patients with neurological and/or traumatic injuries in the intensive care unit (ICU), identifies literature gaps and provides recommendations for future research.

MATERIALS AND METHODS

We searched five databases from inception to June 2, 2018. We included published retrospective studies, case studies, observation and randomized controlled trials describing physiotherapy interventions in ICU patients with neurotrauma injuries. Two reviewers reviewed the databases and independently screened English articles for eligibility. Data extracted included purpose, study design, population (s), outcome measures, interventions and results. Thematic analysis and descriptive numerical summaries are presented by intervention type.

RESULTS

12,846 titles were screened and 72 met the inclusion criteria. Most of the studies were observational studies (44 (61.1%)) and RCTs (14 (19.4%)). Early mobilization, electrical stimulation, range of motion, and chest physiotherapy techniques were the most common interventions in the literature. Physiotherapy interventions were found to be safe with few adverse events.

CONCLUSIONS

Gaps in the literature suggest that future studies require assessment of long term functional outcomes and quality of life, examination of homogenous populations and more robust methodologies including clinical trials and larger samples.

Inspiratory muscle training for intensive care patients: A multidisciplinary practical guide for clinicians

OBJECTIVES

To describe a multidisciplinary approach to inspiratory muscle training (IMT) for patients in the intensive care unit (ICU).

BACKGROUND

Inspiratory muscle weakness is a known consequence of prolonged mechanical ventilation, and there is emerging evidence that specific IMT can ameliorate this weakness. However, IMT is not yet standard practice in many ICUs, possibly because of the wide variety of methods reported and a lack of published practical guidelines. While the optimal parameters for IMT are yet to be established, we share our detailed methodology which has been shown to be safe in selected ventilator-dependent patients and is the only approach which has been shown to increase quality of life in ICU patients.

METHODS

Patients who have experienced invasive mechanical ventilation for at least 7 days can commence IMT in either the ventilator-dependent phase or when weaned from mechanical ventilation. Intensity should be prescribed based on maximum inspiratory pressure, which is measurable through the tracheostomy or endotracheal tube via the ventilator or a respiratory pressure meter. Using a removable threshold device, we recommend high-intensity training (5 sets of 6 breaths at a minimum of 50% of maximum inspiratory pressure) performed once per day, supervised by the physiotherapist, with intensity increased daily such that patients can only just complete the 6th breath in each set.

RESULTS

Using this high-intensity approach, IMT is likely to improve not only inspiratory muscle strength but also quality of life in patients recently weaned from mechanical ventilation of 7 days' duration or longer. Effective IMT requires a multidisciplinary approach to maximise feasibility, with doctors, nurses, and therapists working closely to optimise conditions for successful IMT.

CONCLUSIONS

This multidisciplinary approach to implement IMT in ICU patients should assist clinicians in translating best-available evidence into practice, with the potential to enhance patient recovery.

Acute bag-valve breathing maneuvers plus manual chest compression is safe during stable septic shock: a randomized clinical trial

Objective

To evaluate the effects of bag-valve breathing maneuvers combined with standard manual chest compression techniques on safety, hemodynamics and oxygenation in stable septic shock patients.

Design

A parallel, assessor-blinded, randomized trial of two groups. A computer-generated list of random numbers was prepared by an independent researcher to allocate treatments.

Setting

The Intensive Care Unit at Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul.

Participants

Fifty-two subjects were assessed for eligibility, and 32 were included. All included subjects (n = 32) received the allocated intervention (n = 19 for the Experimental Group and n = 13 for the Control Group).

Intervention

Twenty minutes of bag-valve breathing maneuvers combined with manual chest compression techniques (Experimental Group) or chest compression, as routinely used at our intensive care unit (Control Group). Follow-up was performed immediately after and at 30 minutes after the intervention.

Main outcome measure

Mean artery pressure.

Results

All included subjects completed the trial (N = 32). We found no relevant effects on mean artery pressure (p = 0.17), heart rate (p = 0.50) or mean pulmonary artery pressure (p = 0.89) after adjusting for subject age and weight. Both groups were identical regarding oxygen consumption after the data adjustment (p = 0.84). Peripheral oxygen saturation tended to increase over time in both groups (p = 0.05), and there was no significant association between cardiac output and venous oxygen saturation (p = 0.813). No clinical deterioration was observed.

Conclusion

A single session of bag-valve breathing maneuvers combined with manual chest compression is hemodynamically safe for stable septic-shocked subjects over the short-term.

The scope of physiotherapy services provided in public ICUs in Greece: A pilot study

The aim of the present study was to determine the scope of physiotherapy services provided in Greek ICUs in Athens. A cross-sectional study was conducted with two postal questionnaires administered separately, one for ICU directors and one for ICU physiotherapists. Responses were received from 19 ICU directors and 103 physiotherapists employed in all the adult public mixed medical and surgical ICUs across Athens. The response rate for the survey completion was 100% for ICU directors and 68.7% for physiotherapists. The results showed a 1:50 to 1:12 range in the ratio of physiotherapists to ICU beds. Among the 19 ICUs, 15 (78.9%) employed physiotherapists on a rotational basis, while four (21.0%) retained them exclusively. On weekdays, all surveyed ICUs were covered by physiotherapists in the morning and 10/19 (52.6%) during the afternoon. On weekends, 12/19 (63.2%) of the surveyed ICUs reported physiotherapy care during the morning and 4/19 (21.0%) during both morning and afternoon. All 103 physiotherapists conducted airway clearance techniques and progressive mobilization, 92/103 (89.3%) were involved in extubating patients, 102/103 (99.0%) in passive and active range of motion exercises, and 61/103 (59.2%) in walking. In conclusion, all Greek ICUs in Athens surveyed had physiotherapy cover. The physiotherapists working in these ICUs in Athens were involved in respiratory care and mobilization.

Challenges in Providing Timely Physiotherapy and Opportunities to Influence Outcomes for Potential Lung Donors

CONTEXT

There is a critical shortage of donor lungs however, considerable ethical considerations are associated with the conduct of research to optimize care of the potential organ donor.

OBJECTIVE

To investigate pathways of consent, respiratory care by physiotherapists and donation rates to contextualize future research on physiotherapy effects on donor lung suitability for procurement.

DESIGN

Retrospective audit.

SETTING

Australian tertiary hospital.

PATIENTS

Potential organ donors (defined as patients who may have been eligible to donate organs for transplantation via either brain death or circulatory death) 75 years or younger presenting to the emergency department or the intensive care unit (ICU) between September 2011 and December 2012.

MAIN OUTCOME MEASURES

Donation rates, timing of organ procurement from initial hospital presentation, number of persons designated to make health-care decisions approached for and consenting to donation and clinical research, and number of patients assessed and/or treated by physiotherapists.

RESULTS

Records of 65 potentially eligible donors were analyzed. Eighteen (28%) of the 65 became donors. Organ procurement occurred at a median of 48 hours (interquartile range: 34-72 hours) after ICU admission. All decision-makers approached regarding participation in clinical research (4 [6%] of the 65) consented. Physiotherapists assessed 48 (74%) of the 65 patients at least once and provided 28 respiratory treatments to 18 (28%) of the 65 patients, including lung hyperinflation and positioning. Limitations were the retrospective, single-center design and the "potential organ donor" definition.

CONCLUSION

Organ procurement occurs early. There is potential for early intervention to improve lung donor rates. Randomized controlled trials investigating protocolized respiratory packages of care may increase the potential donor pool and transplantation rates.

Effectiveness of a Very Early Stepping Verticalization Protocol in Severe Acquired Brain Injured Patients: A Randomized Pilot Study in ICU

BACKGROUND AND OBJECTIVE

Verticalization was reported to improve the level of arousal and awareness in patients with severe acquired brain injury (ABI) and to be safe in ICU. We evaluated the effectiveness of a very early stepping verticalization protocol on their functional and neurological outcome.

METHODS

Consecutive patients with Vegetative State or Minimally Conscious State were enrolled in ICU on the third day after an ABI. They were randomized to undergo conventional physiotherapy alone or associated to fifteen 30-minute sessions of verticalization, using a tilt table with robotic stepping device. Once stabilized, patients were transferred to our Neurorehabilitation unit for an individualized treatment. Outcome measures (Glasgow Coma Scale, Coma Recovery Scale revised -CRSr-, Disability Rating Scale-DRS- and Levels of Cognitive Functioning) were assessed on the third day from the injury (T0), at ICU discharge (T1) and at Rehab discharge (T2). Between- and within-group comparisons were performed by the Mann-Whitney U test and Wilcoxon signed-rank test, respectively.

RESULTS

Of the 40 patients enrolled, 31 completed the study without adverse events (15 in the verticalization group and 16 in the conventional physiotherapy). Early verticalization started 12.4±7.3 (mean±SD) days after ABI. The length of stay in ICU was longer for the verticalization group (38.8 ± 15.7 vs 25.1 ± 11.2 days, p = 0.01), while the total length of stay (ICU+Neurorehabilitation) was not significantly different (153.2 ± 59.6 vs 134.0 ± 61.0 days, p = 0.41). All outcome measures significantly improved in both groups after the overall period (T2 vs T0, p<0.001 all), as well as after ICU stay (T1 vs T0, p<0.004 all) and after Neurorehabilitation (T2 vs T1, p<0.004 all). The improvement was significantly better in the experimental group for CRSr (T2-T0 p = 0.033, T1-T0 p = 0.006) and (borderline) for DRS (T2-T0 p = 0.040, T1-T0 p = 0.058).

CONCLUSIONS

A stepping verticalization protocol, started since the acute stages, improves the short-term and long-term functional and neurological outcome of ABI patients.

TRIAL REGISTRATION

clinicaltrials.gov NCT02828371.

Mobilization of patients in neurological Intensive Care Units of India: A survey

Context:

The rehabilitation needs of the patients in neurological Intensive Care Units (ICUs) vary from that of a medical ICU patient. Early mobilization is known to improve the various neurological outcomes in patients admitted to neurological ICUs, although little is known about the practice pattern among physiotherapists. The mobilization practice pattern may vary significantly than that of developed countries due to the reasons of differences in training of professionals, availability of equipment, and financial assistance by health insurance.

Aim of the Study:

To study the current mobilization practices by the physiotherapists in neurological ICUs of India.

Subjects and Methods:

A cross-sectional survey was conducted with a content validated questionnaire about the mobilization practices. Online questionnaire was distributed to physiotherapists working in neurological ICUs of India. Descriptive statistics were used.

Results:

Out of 185 e-mails sent, 82 physiotherapists completed the survey (survey response rate = 44%). Eighty participants (97.6%) mentioned that the patients received some form of mobilization during the day. The majority of the physiotherapists (58.5%), “always” provided bed mobility exercises to their patients when it was found appropriate for the patients. Many physiotherapists (41.5%) used tilt table “sometimes” to introduce orthostatism for their patients.

Conclusion:

Mobilization in various forms is being practiced in the neurological ICUs of India. However, fewer mobilization sessions are conducted on weekends and night hours in Indian Neurological ICUs.

[Short version S2e guidelines: "Positioning therapy and early mobilization for prophylaxis or therapy of pulmonary function disorders"]

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioned a revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientific relevance the guidelines were extended to include the issue of "early mobilization" and the following main topics are therefore included: use of positioning therapy and early mobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

[Impact of a continuous education program on the quality of assistance offered by intensive care physiotherapy]

Objective

To evaluate the role of quality indicators and adverse events registering in the quality assessment of intensive care physiotherapy and to evaluate the impact of implementing protocolized care and professional training in the quality improvement process.

Methods

A prospective before-after study was designed to assess 15 indicators of the quality of care. Baseline compliance and adverse events were collected before and after the implementation of treatment protocols and staff training.

Results

Eighty-nine patients admitted, being 48 in the pre-intervention period and 41 in the post-intervention period with a total of 1246 and 1191 observations respectively. Among the indicators related to the global population, there was a significant improvement in chest x-ray control, multidisciplinary rounds and shift changes as well as in compliance with these decisions. Indicators related to the population under mechanical ventilation, obtained by direct observation at bedside, showed a significant improvement in the compliance with the tidal volume of 6-8mL/Kg, plateau pressure <30cmH₂O, adequate mechanical ventilation alarm setting, mechanical ventilation humidification control, adequate humidification line exchange and orotracheal tube position. Among the mechanical ventilation indicators collected through the physiotherapy records, there was significantly improved compliance with the predicted tidal volume registry and cuff pressure registry. There was a significant reduction in the number of adverse events. There was no impact on intensive care unit mortality, length of stay, duration of mechanical ventilation and ventilator-free days.

Conclusion

It is possible to measure the quality of physiotherapy care using indicators of quality control. The implementation of care protocols and training of the professionals can improve team performance.

Profile of patients and physiotherapy patterns in intensive care units in public hospitals in Zimbabwe: a descriptive cross-sectional study

Background

Physiotherapy is integral to patient management in the Intensive Care Unit. The precise role that physiotherapists play in the critical care differs significantly worldwide. The aim of the study was to describe the profile of patients and the current patterns of physiotherapy services delivered for patients admitted in the five public hospital intensive care units in Zimbabwe.

Methods

A prospective record review was performed and records of all consecutive patients admitted into the five units during a two months period were included in the analysis. The data was collected using a checklist and the following were recorded for each patient: 1) demographic information, 2) admission diagnoses, 3) surgery classification, 4) method and time of mechanical ventilation 5) physiotherapy techniques and frequency and 6) the length of stay.

Results

A total of 137 patients were admitted to five units during the study. The mean age of patients in the study was 36.0 years (SD = 16.6). A mortality rate of 17.5 % was observed with most of the patients being below the age of 45 years. The majority of the patients, 61(45 %) had undergone emergency surgery and were in the ICU for postoperative treatment, whilst only 19(14 %) were in the units for clinical treatment (non-surgical). On admission, 72(52.6 %) of the patients were on mechanical ventilation. The mean duration on mechanical ventilation for patients was 4.0 days (SD =2.7) and a length of stay in the unit of 4.5 days (SD = 3.0).

Of the patients who were admitted into the ICU 120 (87.6 %) had at least one session of physiotherapy treatment during their stay. The mean number of days physiotherapy treatment was received was 3.71 (SD = 3.14) days. The most commonly used physiotherapy techniques were active assisted limb movements (66.4 %), deep breathing exercises (65.0 %) and forced expiratory techniques (65.0 %).

Conclusion

A young population admitted in the ICU for post-surgical treatment was observed across all hospital ICUs. The techniques which were executed in Zimbabwean ICUs showed that the goal of the physiotherapy treatment was mainly to prevent and treat respiratory complications and a culture of promoting bed rest still existed.

Trial registration

PACTR201408000829202

Clinical effects of specialist and on-call respiratory physiotherapy treatments in mechanically ventilated children: A randomised crossover trial

OBJECTIVES

The study investigated treatment outcomes when respiratory physiotherapy was delivered by non-respiratory on-call physiotherapists, compared with specialist respiratory physiotherapists.

DESIGN

Prospective, randomised crossover trial.

SETTING

Paediatric, tertiary care hospital in the United Kingdom.

PARTICIPANTS

Mechanically ventilated children requiring two physiotherapy interventions during a single day were eligible. Twenty two physiotherapists (10 non-respiratory) and 93 patients were recruited.

INTERVENTIONS

Patients received one treatment from a non-respiratory physiotherapist and another from a respiratory physiotherapist, in a randomised order. Treatments were individualised to the patients' needs, often including re-positioning followed by manual lung inflations, chest wall vibrations and endotracheal suction.

MAIN OUTCOME MEASURES

The primary outcome was respiratory compliance. Secondary outcomes included adverse physiological events and clinically important respiratory changes (according to an a priori definition).

RESULTS

Treatments delivered to 63 patients were analysed. There were significant improvements to respiratory compliance (mean increase [95% confidence intervals], 0.07 and 0.08ml·cmH2O(-1)·kg(-1) [0.01 to 0.14 and 0.04 to 0.13], p<0.01, for on-call and respiratory physiotherapists' treatments respectively). Case-by-case, there were fewer clinically important improvements following non-respiratory physiotherapists' treatments compared with the respiratory physiotherapists' (n=27 [43%] versus n=40 [63%], p=0.03). Eleven adverse events occurred, eight following non-respiratory physiotherapists' treatments.

CONCLUSIONS

Significant disparities exist in treatment outcomes when patients are treated by non-respiratory on-call physiotherapists, compared with specialist respiratory physiotherapists. There is an urgent need for targeted training strategies, or alternative service delivery models, to be explored. This should aim to address the quality of respiratory physiotherapy services, both during and outside of normal working hours.

CLINICAL TRIAL REGISTRATION NUMBER

Clinicaltrials.gov, NCT01999426.

Impact of using physiotherapy self-referral in the medical-surgical neurological intensive care unit

PURPOSE

To describe physiotherapy (PT) referral practice in a medical-surgical neurological intensive care unit (MSNICU) of a large quaternary teaching hospital before and after the implementation of PT self-referral.

METHODS

Charts were reviewed for MSNICU patients who received PT pre-implementation (Pre; n=90) and post-implementation (Post; n=100) to collect data on timeliness, number of referrals, and MSNICU length of stay (LOS); t-tests were conducted to determine group differences.

RESULTS

The mean age of MSNICU patients referred to PT was 60.6 (SD=18.6) years; 59.5% were male. PT treatment consisted of cardiorespiratory (39% Pre, 51.1% Post), mobility (22% Pre, 28.8% Post), and combined (39% Pre, 20% Post) interventions. Overall, the number of days between MSNICU admission and PT initiation and MSNICU LOS did not differ significantly from Pre to Post. However, for patients (n=50) receiving early (within 7 days of MSNICU admission) PT self-referral Post versus patients receiving physician referral only Pre (n=83), there was a significant decrease (p=0.01) in time to PT initiation of 1.4 days (3.2 Pre, 1.8 Post).

CONCLUSIONS

PT self-referral increased both the number of patients receiving more timely access to PT and the provision of treatment of a deferred group of patients previously not referred. Future studies need to evaluate the impact of referral methods across a variety of clinical populations.

Muscle wasting and early mobilization in acute respiratory distress syndrome

Survivors of acute respiratory distress syndrome often sustain muscle wasting and functional impairment related to intensive care unit (ICU)-acquired weakness (ICUAW) and this disability may persist for years after ICU discharge. Early diagnosis in cooperative patients by physical examination is recommended to identify patients at risk for weaning failure and to minimize prolongation of risk factors for ICUAW. When possible, early rehabilitation in critically ill patients improves functional outcomes, likely by reducing disuse atrophy. Interventions designed to correct the functional impairment are lacking and further research to delineate the molecular pathways that give rise to ICUAW are needed.

Acute hemodynamic responses to 30° head-down postural drainage in stable, ventilated trauma patients: a randomized crossover trial

OBJECTIVE

To determine whether 30° head-down tilt (HDT) used for secretion clearance is safe for acute trauma patients.

BACKGROUND

There are concerns that HDT may lead to cardiac irregularities in intubated patients in the ICU.

METHODS

Eleven mechanically ventilated trauma patients (25-42 yrs) without cardiovascular problems received two interventions, one supine HDT for 10 min and a control in the horizontal supine position (HS), in a crossover design.

RESULTS

Compared to baseline there were statistically significant (p < 0.05) increases in SBP (6.3 mm Hg; 95% CI 2.5, 12.7) and CVP (7.3 cm H2O; 5.7, 10.0) during 10 min HDT although these were not of clinical concern. Heart rate and oxygen saturation were unchanged. No episodes of arrhythmia or hypoxemia were observed. All values returned close to baseline during 10 min horizontal recovery. There were no significant changes during the control HS intervention.

CONCLUSION

30° HDT entails minimal risk for trauma patients who have no underlying cardiovascular disease.

Acute effects of physiotherapeutic respiratory maneuvers in critically ill patients with craniocerebral trauma

OBJECTIVE

To evaluate the effects of physiotherapeutic respiratory maneuvers on cerebral and cardiovascular hemodynamics and blood gas variables.

METHOD

A descriptive, longitudinal, prospective, nonrandomized clinical trial that included 20 critical patients with severe craniocerebral trauma who were receiving mechanical ventilation and who were admitted to the intensive care unit. Each patient was subjected to the physiotherapeutic maneuvers of vibrocompression and increased manual expiratory flow (5 minutes on each hemithorax), along with subsequent airway suctioning with prior instillation of saline solution, hyperinflation and hyperoxygenation. Variables related to cardiovascular and cerebral hemodynamics and blood gas variables were recorded after each vibrocompression, increased manual expiratory flow and airway suctioning maneuver and 10 minutes after the end of airway suctioning.

RESULTS

The hemodynamic and blood gas variables were maintained during vibrocompression and increased manual expiratory flow maneuvers; however, there were increases in mean arterial pressure, intracranial pressure, heart rate, pulmonary arterial pressure and pulmonary capillary pressure during airway suctioning. All of the values returned to baseline 10 minutes after the end of airway suctioning.

CONCLUSION

Respiratory physiotherapy can be safely performed on patients with severe craniocerebral trauma. Additional caution must be taken when performing airway suctioning because this technique alters cerebral and cardiovascular hemodynamics, even in sedated and paralyzed patients.

Blood flow velocity and vascular resistance during passive leg exercise in the critically ill patient

Passive range of motion exercise is a very common physical therapy treatment for patients admitted to an intensive care unit. However is the knowledge scarce regarding its impact on blood circulation in the extremities. The objective of this study was therefore to investigate the effect of passive range of motion on arterial peripheral leg blood flow velocity (BFV) and vascular resistance. A cross-sectional consecutive study of twelve patients admitted to an intensive care unit and twelve healthy age- and gender-matched controls was conducted. Passive range of motion was performed in one leg by a physical therapist. Blood flow velocities and resistance index in the common femoral artery (CFA), blood pressure and heart rate were measured before, directly after and at rest after passive range of motion. No changes were seen in BFV or resistance index in the patient group or the control group. No changes were found in blood pressure or heart rate in the patient group. In the control group, changes were found in systolic and mean blood pressure, with a higher pressure before passive range of motion. The controls had lower BFV and higher resistance index than the patients when comparing the groups. The conclusion of this study including twelve patients is that passive range of motion does not alter BFV or resistance index in the CFA in comatose and/or sedated critically ill patients.

Specific inspiratory muscle training is safe in selected patients who are ventilator-dependent: a case series

BACKGROUND

Mechanical ventilation of intensive care patients results in inspiratory muscle weakness. Inspiratory muscle training may be useful, but no studies have specifically described the physiological response to training.

RESEARCH QUESTIONS

Is inspiratory muscle training with a threshold device safe in selected ventilator-dependent patients? Does inspiratory muscle strength increase with high-intensity inspiratory muscle training in ventilator-dependent patients?

DESIGN

Prospective cohort study of 10 medically stable ventilator-dependent adult patients.

SETTING

Tertiary adult intensive care unit.

METHODS

Inspiratory muscle training 5-6 days per week with a threshold device attached to the tracheostomy without supplemental oxygen.

OUTCOME MEASURES

Physiological response to training (heart rate, mean arterial pressure, oxygen saturation and respiratory rate), adverse events, training pressures.

RESULTS

No adverse events were recorded in 195 sessions studied. For each patient's second training session, no significant changes in heart rate (Mean Difference 1.3 bpm, 95% CI -2.7 to 5.3), mean arterial pressure (Mean Difference -0.9 mmHg, 95% CI -6.4 to 4.6), respiratory rate (Mean Difference 1.2 bpm, 95% CI -1.1 to 3.5 bpm) or oxygen saturation (Mean Difference 1.2%, 95% CI -0.6 to 3.0) were detected Training pressures increased significantly (Mean Difference 18.6 cmH(2)O, 95% CI 11.8-25.3).

CONCLUSION

Threshold-based inspiratory muscle training can be delivered safely in selected ventilator-dependent patients without supplemental oxygen. Inspiratory muscle training is associated with increased muscle strength, which may assist ventilatory weaning.

Protocol: inspiratory muscle training for promoting recovery and outcomes in ventilated patients (IMPROVe): a randomised controlled trial

INTRODUCTION

Inspiratory muscle weakness is a known consequence of mechanical ventilation and a potential contributor to difficulty in weaning from ventilatory support. Inspiratory muscle training (IMT) reduces the weaning period and increases the likelihood of successful weaning in some patients. However, it is not known how this training affects the residual inspiratory muscle fatigability following successful weaning nor patients' quality of life or functional outcomes.

METHODS AND ANALYSIS

This dual centre study includes two concurrent randomised controlled trials of IMT in adult patients who are either currently ventilator-dependent (>7 days) (n=70) or have been recently weaned from mechanical ventilation (>7 days) in the past week (n=70). Subjects will be stable, alert and able to actively participate and provide consent. There will be concealed allocation to either treatment (IMT) or usual physiotherapy (including deep breathing exercises without a resistance device). Primary outcomes are inspiratory muscle fatigue resistance and maximum inspiratory pressures. Secondary outcomes are quality of life (Short Form-36v2, EQ-5D), functional status (Acute Care Index of Function), rate of perceived exertion (Borg Scale), intensive care length of stay (days), post intensive care length of stay (days), rate of reintubation (%) and duration of ventilation (days).

ETHICS AND DISSEMINATION

Ethics approval has been obtained from relevant institutions, and results will be published with a view to influencing physiotherapy practice in the management of long-term ventilator-dependent patients to accelerate weaning and optimise rehabilitation outcomes.

TRIAL REGISTRATION NUMBER

ACTRN12610001089022.

Early rehabilitation in sepsis: a prospective randomised controlled trial investigating functional and physiological outcomes The i-PERFORM Trial (Protocol Article)

BACKGROUND

Patients with sepsis syndromes in comparison to general intensive care patients can have worse outcomes for physical function, quality of life and survival. Early intensive care rehabilitation can improve the outcome in general Intensive Care Unit (ICU) patients, however no investigations have specifically looked at patients with sepsis syndromes. The 'i-PERFORM Trial' will investigate if early targeted rehabilitation is both safe and effective in patients with sepsis syndromes admitted to ICU.

METHODS/DESIGN

A single-centred blinded randomized controlled trial will be conducted in Brisbane, Australia. Participants (n = 252) will include those ≥ 18 years, mechanically ventilated for ≥ 48 hours and diagnosed with a sepsis syndrome. Participants will be randomised to an intervention arm which will undergo an early targeted rehabilitation program according to the level of arousal, strength and cardiovascular stability and a control group which will receive normal care.The primary outcome measures will be physical function tests on discharge from ICU (The Acute Care Index of Function and The Physical Function ICU Test). Health-related quality of life will be measured using the Short Form-36 and the psychological component will be tested using The Hospital Anxiety and Depression Scale. Secondary measures will include inflammatory biomarkers; Interleukin-6, Interleukin-10 and Tumour Necrosis Factor-α, peripheral blood mitochondrial DNA content and lactate, fat free muscle mass, tissue oxygenation and microcirculatory flow.

DISCUSSION

The 'i-PERFORM Trial' will determine whether early rehabilitation for patients with sepsis is effective at improving patient outcomes with functional and physiological parameters reflecting long and short-term effects of early exercise and the safety in its application in critical illness.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000808044.

Manual therapies for migraine: a systematic review

Migraine occurs in about 15% of the general population. Migraine is usually managed by medication, but some patients do not tolerate migraine medication due to side effects or prefer to avoid medication for other reasons. Non-pharmacological management is an alternative treatment option. We systematically reviewed randomized clinical trials (RCTs) on manual therapies for migraine. The RCTs suggest that massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy might be equally effective as propranolol and topiramate in the prophylactic management of migraine. However, the evaluated RCTs had many methodological shortcomings. Therefore, any firm conclusion will require future, well-conducted RCTs on manual therapies for migraine.