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Twose P, Peirce S, Maisey J, Jones L, Nunn J. Ventilator-tube holder for mobilising patients with a tracheostomy: A pilot usability study (TrachVest). Aust Crit Care 2024:S1036-7314(24)00113-9. [PMID: 38960743 DOI: 10.1016/j.aucc.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/09/2024] [Accepted: 05/31/2024] [Indexed: 07/05/2024] Open
Abstract
INTRODUCTION Patients in intensive care may have a tracheostomy and be dependent on a respiratory ventilator while yet conscious and able to mobilise. Early rehabilitation is known to be key to patient recovery. However, for these patients, therapy staff members are required to manage the ventilator tubing in addition to other patient-connected equipment whilst focussing on patient mobility and progress. A technical garment (TrachVest) was designed to hold the ventilator tubing securely during these therapeutic mobilisations. METHODS We conducted a mixed-methods study to evaluate the use of this garment in an intensive care unit setting. The aim was to determine potential effects on patient safety, its potential benefits, and usability. Research methods included direct observations, user questionnaires (quantitative and qualitative), and staff focus groups. RESULTS A total of 14 therapy sessions with the garment were observed, involving nine patients and 10 staff. Eleven staff members participated in two focus groups, including two previously involved in the therapy sessions. Therapy sessions consisted of a range of activities including sitting on the edge of the bed, transferring from bed to chair (including use of hoists), and mobilising with walking aids. Overall, staff members felt that the garment was easy to use and would likely improve patient safety during mobilisations. The main benefits were staff reassurance, allowing them to focus on therapy, and in potentially reducing the number of staff members needed for particular activities. Patient characteristics were found to be influential on the perceived utility, and TrachVest may have greater benefit for patients who have greater physical function (e.g., able to actively participate in rehabilitation) and can mobilise at least from bed to chair. Experience of using the TrachVest and of patient capabilities was thought to be key to knowing when it would be most useful. CONCLUSION Within this pilot usability study, participants, both staff and patients, reported that the TrachVest garment designed to support ventilator tubing during rehabilitation to be highly useable and beneficial to supporting rehabilitation in this patient group.
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Affiliation(s)
- Paul Twose
- Physiotherapy Department, University Hospital of Wales, Cardiff, CF14 4XW, UK; School of Healthcare Sciences, Cardiff University, Cardiff CF144XN, UK.
| | - Susan Peirce
- Cedar, Cardiff Medicentre, Heath Park, CF14 4UJ, UK.
| | - John Maisey
- Mechanical Section, Clinical Engineering, Medical Physics Corridor, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK.
| | - Laura Jones
- Physiotherapy Department, University Hospital of Wales, Cardiff, CF14 4XW, UK.
| | - Jason Nunn
- Physiotherapy Department, University Hospital of Wales, Cardiff, CF14 4XW, UK.
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Gutierrez-Arias R, Pieper D, Nydahl P, González-Seguel F, Jalil Y, Oliveros MJ, Torres-Castro R, Seron P. Assessment of redundancy, methodological and reporting quality, and potential discrepancies of results of systematic reviews of early mobilisation of critically ill adults: a meta-research protocol. BMJ Open 2023; 13:e074615. [PMID: 37474166 PMCID: PMC10360432 DOI: 10.1136/bmjopen-2023-074615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/28/2023] [Indexed: 07/22/2023] Open
Abstract
INTRODUCTION Several systematic reviews (SRs) have been conducted to determine the effectiveness of early mobilisation in critically ill adults with heterogeneous methodology and results. Redundancy in conducting SRs, unclear justification when leading new SRs or updating, and discordant results of SRs on the same research question may generate research waste that makes it difficult for clinicians to keep up to date with the best available evidence. This meta-research aims to assess the redundancy, methodological and reporting quality, and potential reasons for discordance in the results reported by SRs conducted to determine the effectiveness of early mobilisation in critically ill adult patients. METHODS AND ANALYSIS A meta-research of early mobilisation SRs in critically ill adult patients will be conducted. A search of MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Cochrane Library, Epistemonikos and other search resources will be conducted. Two independent reviewers will perform study selection, data extraction and quality appraisal. Discrepancies will be resolved by consensus or a third reviewer. The redundancy of SRs will be assessed by the degree of overlap of primary studies. In addition, the justification for conducting new SRs will be evaluated with the 'Evidence-Based Research' framework. The methodological quality of the SRs will be assessed with the A MeaSurement Tool to Assess systematic Reviews 2 tool, and the quality of the reports through compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. To assess the potential reasons for discordance in the results of the SRs considering divergence in results and their interpretation. ETHICS AND DISSEMINATION As meta-research, this study does not involve the participation of people whose rights may be violated. However, this overview will be developed rigorously and systematically to achieve valid and reliable results. The findings of this meta-research study will be presented at conferences and published in a peer-reviewed journal related to rehabilitation, critical care or research methodology. TRIAL REGISTRATION NUMBER osf.io/kxwq9.
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Affiliation(s)
- Ruvistay Gutierrez-Arias
- Departamento de Apoyo en Rehabilitación Cardiopulmonar Integral, Instituto Nacional del Tórax, Santiago, Chile
- Exercise and Rehabilitation Sciences Institute, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago 7591538, Chile
- INTRehab Research Group, Instituto Nacional del Tórax, Santiago, Chile
| | - Dawid Pieper
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School (Theodor Fontane), Institute for Health Services and Health Systems Research, Rüdersdorf, Germany
- Center for Health Services Research, Brandenburg Medical School (Theodor Fontane), Rüdersdorf, Germany
| | - Peter Nydahl
- Department of Nursing Research, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Felipe González-Seguel
- Servicio de Medicina Física y Rehabilitación and Departamento de Paciente Crítico, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Yorschua Jalil
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Departamento de Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Maria-Jose Oliveros
- Departamento de Ciencias de la Rehabilitación, Universidad de La Frontera, Temuco, Chile
- Centro de Excelencia CIGES, Universidad de La Frontera, Temuco, Chile
| | | | - Pamela Seron
- Departamento de Ciencias de la Rehabilitación, Universidad de La Frontera, Temuco, Chile
- Centro de Excelencia CIGES, Universidad de La Frontera, Temuco, Chile
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Gutierrez-Arias R, Nydahl P, Pieper D, González-Seguel F, Jalil Y, Oliveros MJ, Torres-Castro R, Seron P. Effectiveness of physical rehabilitation interventions in critically ill patients-A protocol for an overview of systematic reviews. PLoS One 2023; 18:e0284417. [PMID: 37053257 PMCID: PMC10101388 DOI: 10.1371/journal.pone.0284417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/26/2023] [Indexed: 04/14/2023] Open
Abstract
INTRODUCTION Adult and pediatric patients admitted to intensive care units (ICUs) requiring invasive ventilatory support, sedation, and muscle blockade may present neuromusculoskeletal deterioration. Different physical rehabilitation interventions have been studied to evaluate their effectiveness in improving critically ill patients' outcomes. Given that many published systematic reviews (SRs) aims to determine the effectiveness of different types of physical rehabilitation interventions, it is necessary to group them systematically and assess the methodological quality of SRs to help clinicians make better evidence-based decisions. This overview of SRs (OoSRs) aims to map the existing evidence and to determine the effectiveness of physical rehabilitation interventions to improve neuromusculoskeletal function and other clinical outcomes in adult and pediatric critically ill patients. METHODS An OoSRs of randomized and non-randomized clinical trials involving critically ill adult and pediatric patients receiving physical rehabilitation intervention will be conducted. A sensitive search of MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Cochrane Library, Epistemonikos, and other search resources will be conducted. Two independent reviewers will conduct study selection, data extraction, and methodological quality assessment. Discrepancies will be resolved by consensus or a third reviewer. The degree of overlap of studies will be calculated using the corrected covered area. The methodological quality of the SRs will be measured using the AMSTAR-2 tool. The GRADE framework will report the certainty of evidence by selecting the "best" SR for each physical rehabilitation intervention and outcome. DISCUSSION The findings of this overview are expected to determine the effectiveness and safety of physical rehabilitation interventions to improve neuromusculoskeletal function in adult and pediatric critically ill patients based on a wide selection of the best available evidence and to determine the knowledge gaps in this topic by mapping and assessing the methodological quality of published SRs. REGISTRATION NUMBER CRD42023389672.
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Affiliation(s)
- Ruvistay Gutierrez-Arias
- Servicio de Medicina Física y Rehabilitación, Unidad de Kinesiología, Instituto Nacional del Tórax, Santiago, Chile
- Exercise and Rehabilitation Sciences Laboratory, Faculty of Rehabilitation Sciences, School of Physical Therapy, Universidad Andres Bello, Santiago, Chile
| | - Peter Nydahl
- Department of Nursing Research, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Dawid Pieper
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School (Theodor Fontane), Institute for Health Services and Health Systems Research, Rüdersdorf, Germany
- Center for Health Services Research, Brandenburg Medical School (Theodor Fontane), Rüdersdorf, Germany
| | - Felipe González-Seguel
- Carrera de Kinesiología, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Yorschua Jalil
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Departamento de Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Maria-Jose Oliveros
- Departamento de Ciencias de la Rehabilitación, Facultad de Medicina, Universidad de La Frontera, Temuco, Chile
- Centro de Excelencia CIGES, Universidad de La Frontera, Temuco, Chile
| | | | - Pamela Seron
- Departamento de Ciencias de la Rehabilitación, Facultad de Medicina, Universidad de La Frontera, Temuco, Chile
- Centro de Excelencia CIGES, Universidad de La Frontera, Temuco, Chile
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Tadyanemhandu C, van Aswegen H, Ntsiea V. Barriers and facilitators to implementation of early mobilisation of critically ill patients in Zimbabwean and South African public sector hospitals: a qualitative study. Disabil Rehabil 2022; 44:6699-6709. [PMID: 34461792 PMCID: PMC9183945 DOI: 10.1080/09638288.2021.1970827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/21/2021] [Accepted: 08/15/2021] [Indexed: 01/13/2023]
Abstract
PURPOSE Implementing early mobilisation in intensive care is challenging, and a detailed knowledge of factors that may hinder or facilitate implementation is essential for success. The study was done to explore the perceived barriers and facilitators to early mobilisation by physiotherapists in Zimbabwean and South African public sector hospital ICUs. METHODS A qualitative study was done in eight public sector hospitals from South Africa and four hospitals from Zimbabwe. Physiotherapists from the participating hospitals who had at least two years working experience in ICU were invited to participate in semi-structured, in-depth, face-to-face interviews. Purposive sampling was done. Data collected included interpretation of early mobilisation, perceived barriers, and facilitators to early mobilisation. Data analysis was done using the content analysis method. FINDINGS A total of 22 physiotherapists were interviewed. In defining the activities regarded as early mobilisation, there was diversity in relation to the specific activities and the nature of the patients in which the defined activities were suitable for. Perceived barriers which emerged included lack of professional autonomy or boundaries, motivation, and clinical skills. Perceived facilitators to early mobilisation included the availability of guidelines, good communication, adequate staff, and mobilisation equipment. CONCLUSIONS Barriers and facilitators to early mobilisation are multifactorial. There is need for multidisciplinary team collaboration and planning before implementing early mobilisation activities.Implications to rehabilitationProfessional roles/identity and or boundaries emerged to be a barrier that hinder implementation of early mobilisation if not clearly defined.Non-rotational physiotherapy coverage was highlighted to be important in facilitating good communication and teamwork and sustainability of services in ICU.Good communication channels and referrals between different disciplines should be employed in ICU to prevent delay in rendering services to ICU patients.
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Affiliation(s)
- Cathrine Tadyanemhandu
- Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Parktown, South Africa
| | - Heleen van Aswegen
- Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Parktown, South Africa
| | - Veronica Ntsiea
- Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Parktown, South Africa
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Effect of Combined Protein-Enriched Enteral Nutrition and Early Cycle Ergometry in Mechanically Ventilated Critically Ill Patients—A Pilot Study. Nutrients 2022; 14:nu14081589. [PMID: 35458151 PMCID: PMC9027967 DOI: 10.3390/nu14081589] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Cycle ergometry (CE) is a method of exercise used in clinical practice. Limited data demonstrate its effectiveness in critically ill patients. We aimed to evaluate the combination of CE and a high-protein diet in critically ill patients. Methods: This was an open label pilot trial comparing conventional physiotherapy with enteral nutrition (EN) (control, Group 1), CE with EN (Group 2), and CE with protein-enriched EN (Group 3). The primary outcome was length of ventilation (LOV). Secondary outcomes were intensive care unit (ICU) mortality, length of ICU stay (ICU LOS), length of hospital stay (Hospital LOS), and rate of re-intubation. Results: Per protocol, 41 ICU patients were enrolled. Thirteen patients were randomized to Group 1 (control), fourteen patients to Group 2, and fourteen patients to Group 3 (study groups). We found no statistically significant difference in LOV between the study arms (14.2 ± 9.6 days, 15.8 ± 7.1 days, and 14.9 ± 9.4 days, respectively, p = 0.89). Secondary outcomes did not demonstrate any significant differences between arms. Conclusions: In this pilot trial, CE combined with either standard EN or protein-enriched EN was not associated with better clinical outcomes, as compared to conventional physiotherapy with standard EN. Larger trials are needed in order to further evaluate this combination.
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Effects of physical therapy with neuromuscular electrical stimulation in acute and late septic shock patients: A randomised crossover clinical trial. PLoS One 2022; 17:e0264068. [PMID: 35176099 PMCID: PMC8853464 DOI: 10.1371/journal.pone.0264068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 01/27/2022] [Indexed: 11/19/2022] Open
Abstract
Background Patients with sepsis and immobility in the intensive care unit are associated with muscle weakness, and early mobilisation can counteract it. However, during septic shock, mobilisation is often delayed due to the severity of the illness. Neuromuscular electrical stimulation (NMES) may be an alternative to mobilise these patients early. This study aims to identify whether NMES performed within the first 72 hours of septic shock diagnosis or later is safe from a metabolic perspective. Methods This is the analysis of two randomised controlled crossover studies. Patients with acute septic shock (within the first 72 hours of diagnosis) and sepsis and septic shock in the late phase (after 72 hours of diagnosis) were eligible. Patients were submitted in a random order to the intervention protocol (dorsal decubitus position with the lower limbs raised and NMES) and control (dorsal decubitus position with the lower limbs raised without NMES). The patients were allocated in group 1 (intervention and control) or group 2 (control and intervention) with a wash-out period of 4 to 6 hours. Metabolic variables were evaluated by indirect calorimetry. Results Sixteen patients were analysed in the acute septic shock study and 21 in the late sepsis/septic shock study. There were no significant differences between Oxygen Consumption (VO2) values in the acute phase of septic shock when the baseline period, intervention, and control protocols were compared (186.59 ± 46.10; 183.64 ± 41.39; 188.97 ± 44.88, p>0.05- expressed in mL/Kg/min). The same was observed when the VO2 values in the late phase were compared (224.22 ± 53.09; 226.20 ± 49.64; 226.79 ± 58.25, p>0.05). The other metabolic variables followed the same pattern, with no significant differences between the protocols. When metabolic variables were compared between acute to late phase, significant differences were observed (p<0.05). Conclusions As metabolic rates in septic shock patients had no increase during NMES, either in the first 72 hours of diagnosis or later, NMES can be considered safe from a metabolic viewpoint, even despite the higher metabolic demand in the acute phase of shock. Trial registration NCT03193164; NCT03815994. Registered on June 5, 2017; November 13, 2018 (clinicaltrials.gov/).
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Skeletal muscle atrophy in critical ill patients and the use of electrical stimulation as a treatment strategy: Recommendations for clinical practice. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ferre M, Batista E, Solanas A, Martínez-Ballesté A. Smart Health-Enhanced Early Mobilisation in Intensive Care Units. SENSORS (BASEL, SWITZERLAND) 2021; 21:5408. [PMID: 34450850 PMCID: PMC8399902 DOI: 10.3390/s21165408] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 12/04/2022]
Abstract
Critically ill patients that stay in Intensive Care Units (ICU) for long periods suffer from Post-Intensive Care Syndrome or ICU Acquired Weakness, whose effects can decrease patients' quality of life for years. To prevent such issues and aiming at shortening intensive care treatments, Early Mobilisation (EM) has been proposed as an encouraging technique: the literature includes numerous examples of the benefits of EM on the prevention of post-operative complications and adverse events. However, the appropriate application of EM programmes entails the use of scarce resources, both human and technical. Information and Communication Technologies can play a key role in reducing cost and improving the practice of EM. Although there is rich literature on EM practice and its potential benefits, there are some barriers that must be overcome, and technology, i.e., the use of sensors, robotics or information systems, can contribute to that end. This article reviews the literature and analyses on the use of technology in the area of EM, and moreover, it proposes a smart health-enhanced scenario.
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Affiliation(s)
| | | | | | - Antoni Martínez-Ballesté
- Department of Computer Engineering and Mathematics, Universitat Rovira i Virgili, E43007 Tarragona, Catalonia, Spain; (M.F.); (E.B.); (A.S.)
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da Rosa Pinheiro DR, Cabeleira MEP, da Campo LA, Corrêa PS, Blauth AHEG, Cechetti F. Effects of aerobic cycling training on mobility and functionality of acute stroke subjects: A randomized clinical trial. NeuroRehabilitation 2021; 48:39-47. [PMID: 33386826 DOI: 10.3233/nre-201585] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Studies demonstrate the benefits of aerobic cycling training in subacute and chronic stroke subjects, but there is a lack in the literature about its effects on the acute phase. OBJECTIVE Verify the effects of aerobic cycling training on lower limbs muscle strength, gait speed, balance, mobility and functionality of acute stroke subjects. METHODS Control group (CG) performed conventional physiotherapy twice a day and the intervention group (IG) performed a conventional physiotherapy and a cycle ergometer session, for five consecutive days. Subjects were assessed for muscle strength by a digital dynamometer, gait speed by the 10-meter-walk-test, balance by the Berg Balance Scale, mobility by the ICU-Mobility-Scale and functionality by the Perme Score. RESULTS Twenty subjects were enrolled in the study, 10 in the CG and 10 in the IG. Lower limbs muscle strength, the main endpoint, was better in the IG compared to the CG. The same was found in the secondary endpoints. The intragroup analysis was also positive for the CG in the mobility and functionality. CONCLUSIONS Conventional physiotherapy combined with cycling exercise showed better results in the improvement of muscle strength of lower limbs, mobility and functionality of subjects who suffered from acute stroke.
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Affiliation(s)
- Douglas Rafael da Rosa Pinheiro
- Universidade Federal de Ciências da Saúde de Porto Alegre, Post-Graduation Program in Rehabilitation Sciences, Porto Alegre, Brazil.,Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | | | - Luigi Antonio da Campo
- Universidade Federal de Ciências da Saúde de Porto Alegre, Post-Graduation Program in Rehabilitation Sciences, Porto Alegre, Brazil
| | - Philipe Souza Corrêa
- Universidade Federal de Ciências da Saúde de Porto Alegre, Post-Graduation Program in Rehabilitation Sciences, Porto Alegre, Brazil
| | - Ariane Haydeé Estrada Gamarra Blauth
- Universidade Federal de Ciências da Saúde de Porto Alegre, Post-Graduation Program in Rehabilitation Sciences, Porto Alegre, Brazil.,Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | - Fernanda Cechetti
- Universidade Federal de Ciências da Saúde de Porto Alegre, Post-Graduation Program in Rehabilitation Sciences, Porto Alegre, Brazil
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Tadyanemhandu C, van Aswegen H, Ntsiea V. Organizational structures and early mobilization practices in South African public sector intensive care units-A cross-sectional study. J Eval Clin Pract 2021; 27:42-52. [PMID: 32141685 PMCID: PMC7483254 DOI: 10.1111/jep.13378] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/15/2020] [Accepted: 02/03/2020] [Indexed: 12/12/2022]
Abstract
RATIONALE Understanding current early mobilization practice of patients in intensive care unit (ICU) is critical to the design and implementation of strategies to facilitate its application in a diverse population of critically ill patients encountered in public sector hospitals. AIM To evaluate the organizational structures of South African public sector hospital ICUs and to describe early mobilization practices in these units. METHODS A cross-sectional survey was done in participating public hospitals from eight provinces in South Africa. Convenience sampling was done. Data collected included hospital and ICU structure, adult patient demographic and clinical data, and mobilization activities done in ICU over the previous 24 hours prior to the day of the survey. RESULTS A total of 29 ICUs from 13 participating hospitals were surveyed resulting in 205 patient records. Majority of the surveyed ICUs were "open" type (n = 16; 55.2%). A standardized sedation scoring system was used in 18 units (62.1%) and only two units (6.9%) had an early mobilization protocol in place. Mean age of the patients surveyed was 43.5 (±17.7) years and 148 (72.2%) patients were on mechanical ventilation. Primary reasons for admission to ICU included traumatic injury (n = 86; 42%) and postoperative care (n = 33; 16.1%). Mobilization activities performed in the previous 24 hours included turning the patient in bed (n = 88; 42.9%), marching on the spot (n = 9; 4.4%) and walking (n = 10; 4.9%). Out-of-bed mobilization was done in only 40 (19.5%) patients. The most common barriers to early mobilization included patient unresponsiveness (n = 50; 24.4%) and hemodynamic instability (n = 42; 20.5%). The type of ventilation was found to have a significant positive relationship with out-of-bed patient mobilization (P = .000). CONCLUSIONS A small proportion of patients attained their highest level of mobilization in ICU. The type of ventilation influenced early mobilization practices in public sector ICUs in South Africa.
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Affiliation(s)
- Cathrine Tadyanemhandu
- Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Heleen van Aswegen
- Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Veronica Ntsiea
- Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Three-Fourths of ICU Physical Therapists Report Use of Assistive Equipment and Technology in Practice: Results of an International Survey. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2020. [DOI: 10.1097/jat.0000000000000144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kwakman RCH, Sommers J, Horn J, Nollet F, Engelbert RHH, van der Schaaf M. Steps to recovery: body weight-supported treadmill training for critically ill patients: a randomized controlled trial. Trials 2020; 21:409. [PMID: 32414411 PMCID: PMC7227333 DOI: 10.1186/s13063-020-04333-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/19/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Early mobilization has been proven effective for patients in intensive care units (ICUs) to improve functional recovery. However, early mobilization of critically ill, often mechanically ventilated, patients is cumbersome because of the attachment to tubes, drains, monitoring devices and muscle weakness. A mobile treadmill with bodyweight support may help to initiate mobilization earlier and more effectively. The aim of this study is to assess the effectiveness of weight-supported treadmill training in critically ill patients during and after ICU stay on time to independent functional ambulation. METHODS In this randomized controlled trial, a custom-built bedside body weight-supported treadmill will be used and evaluated. Patients are included if they have been mechanically ventilated for at least 48 hours, are able to follow instructions, have quadriceps muscle strength of Medical Research Council sum-score 2 (MRC 2) or higher, can sit unsupported and meet the safety criteria for physical exercise. Exclusion criteria are language barriers, no prior walking ability, contraindications for physiotherapy or a neurological condition as reason for ICU admission. We aim to include 88 patients and randomize them into either the intervention or the control group. The intervention group will receive usual care plus bodyweight-supported treadmill training (BWSTT) daily. The BWSSTT consists of walking on a mobile treadmill while supported by a harness. The control group will receive usual care physiotherapy treatment daily consisting of progressive activities such as bed-cycling and active functional training exercises. In both groups, we will aim for a total of 40 minutes of physiotherapy treatment time every day in one or two sessions, as tolerated by the patient. The primary outcome is time to functional ambulation as measured in days, secondary outcomes include walking distance, muscle strength, status of functional mobility and symptoms of post-traumatic stress. All measurements will be done by assessors who are blinded to the intervention on the regular wards until hospital discharge. DISCUSSION This will be the first study comparing the effects of BWSTT and conventional physiotherapy for critically ill patients during and after ICU stay. The results of this study contribute to a better understanding of the effectiveness of early physiotherapy interventions for critically ill patients. TRIAL REGISTRATION Dutch Trial Register (NTR) ID: NL6766. Registered at 1 December 2017.
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Affiliation(s)
- Robin C. H. Kwakman
- Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Faculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Education of Physiotherapy, University of Applied Sciences Amsterdam, Amsterdam, The Netherlands
| | - Juultje Sommers
- Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Janneke Horn
- Department of Intensive Care, Neurosciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Frans Nollet
- Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Raoul H. H. Engelbert
- Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Faculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Marike van der Schaaf
- Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Faculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
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Da Campo L, Hauck M, Marcolino MAZ, Pinheiro D, Plentz RDM, Cechetti F. Effects of aerobic exercise using cycle ergometry on balance and functional capacity in post-stroke patients: a systematic review and meta-analysis of randomised clinical trials. Disabil Rehabil 2019; 43:1558-1564. [PMID: 31577467 DOI: 10.1080/09638288.2019.1670272] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Previous studies have shown that aerobic exercise with cycle ergometer improves motor control. PURPOSE The objective of this systematic review and meta-analysis are to evaluate evidence about the effects of aerobic exercise with cycle ergometer on the balance of post-stroke patients, evaluated by the Berg Balance Scale (BBS), and functional capacity, evaluated by the maximal oxygen intake and six-minute walk test (6MWT). METHODS The research was conducted on MEDLINE, LILACS, Cochrane Library, EMBASE, Physiotherapy Evidence Database, and Google Scholar until March 2018 (CRD42015020146). Two independent reviewers performed the article selection, data extraction, and methodological quality assessment. The main outcome was balance assessed by the Berg scale and the secondary outcome was functional capacity of the maximal oxygen intake and the 6MWT. Meta-analysis was conducted using a random-effects method, and mean pre-post intervention difference with a 95% confidence interval (95%CI). RESULTS The review included 5 papers and a total of 258 patients. It was observed that the cycle ergometer did not improve balance in this population (0.03 [-0.57 to 0.64] p = 0.91) or functional capacity in maximal oxygen intake (2.40 [-0.24 to 5.04] p = 0.07) and 6MWT (-40.49 [-131.70 to 50.72] p = 0.38). CONCLUSIONS The cycle ergometer aerobic exercise did not seem to improve balance or functional capacity in post-stroke patients.IMPLICATIONS FOR REHABILITATIONAerobic exercise with cycle ergometer does not improve balance in patients after chronic stroke, but the results for functional capacity are more promising.Beneficial changes in functional capacity can be seen after 12-4 weeks of training, and are dependent on the initial level of physical fitness of each individual.The use of the cycle-ergometer to improve balance and functional capacity was not superior when compared to conventional physiotherapy; therefore, a combination of therapeutic modalities would be ideal for rehabilitation and post-stroke patients.
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Affiliation(s)
- Luigi Da Campo
- Graduate Program of Rehabilitation Sciences, Federal University of Health Sciences, Porto Alegre, Brazil
| | - Melina Hauck
- Graduate Program of Health Sciences, Federal University of Health Sciences, Porto Alegre, Brazil
| | | | - Douglas Pinheiro
- Graduate Program of Rehabilitation Sciences, Federal University of Health Sciences, Porto Alegre, Brazil
| | - Rodrigo Della Méa Plentz
- Graduate Program of Rehabilitation Sciences, Federal University of Health Sciences, Porto Alegre, Brazil.,Graduate Program of Health Sciences, Federal University of Health Sciences, Porto Alegre, Brazil
| | - Fernanda Cechetti
- Graduate Program of Rehabilitation Sciences, Federal University of Health Sciences, Porto Alegre, Brazil
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Parry SM, Chapple LAS, Mourtzakis M. Exploring the Potential Effectiveness of Combining Optimal Nutrition With Electrical Stimulation to Maintain Muscle Health in Critical Illness: A Narrative Review. Nutr Clin Pract 2018; 33:772-789. [PMID: 30358183 DOI: 10.1002/ncp.10213] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Muscle wasting occurs rapidly within days of an admission to the intensive care unit (ICU). Concomitant muscle weakness and impaired physical functioning can ensue, with lasting effects well after hospital discharge. Early physical rehabilitation is a promising intervention to minimize muscle weakness and physical dysfunction. However, there is an often a delay in commencing active functional exercises (such as sitting on the edge of bed, standing and mobilizing) due to sedation, patient alertness, and impaired ability to cooperate in the initial days of ICU admission. Therefore, there is high interest in being able to intervene early through nonvolitional exercise strategies such as electrical muscle stimulation (EMS). Muscle health characterized as the composite of muscle quantity, as well as functional and metabolic integrity, may be potentially maintained when optimal nutrition therapy is provided in complement with early physical rehabilitation in critically ill patients; however, the type, dosage, and timing of these interventions are unclear. This article explores the potential role of nutrition and EMS in maintaining muscle health in critical illness. Within this article, we will evaluate fundamental concepts of muscle wasting and evaluate the effects of EMS, as well as the effects of nutrition therapy on muscle health and the clinical and functional outcomes in critically ill patients. We will also highlight current research gaps in order to advance the field forward in this important area.
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Affiliation(s)
- Selina M Parry
- Department of Physiotherapy, The University of Melbourne, Victoria, Australia
| | - Lee-Anne S Chapple
- Intensive Care Research, Royal Adelaide Hospital, South Australia, Australia
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Koester K, Troeller H, Panter S, Winter E, Patel JJ. Overview of Intensive Care Unit-Related Physical and Functional Impairments and Rehabilitation-Related Devices. Nutr Clin Pract 2018; 33:177-184. [PMID: 29658187 DOI: 10.1002/ncp.10077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Rehabilitation after critical illness requires a multidisciplinary effort. Nutrition support of critically ill patients aims to correct the imbalance between protein synthesis and protein degradation to maximize strengthening and muscle mass, whereas physical and occupational therapists focus on optimizing strength and mobility through functional activity to help intensive care (ICU) patients return to their precritical illness level of function and improve quality of life. Early mobility has become the new standard of care for ICU patients. Therapists utilize various devices and technologies to increase the feasibility of early mobility and enhance the rehabilitation process to ensure that patients reach their rehabilitation goals. Tools such as electrical stimulation, cycle ergometers, dynamic tilt tables, and resistive bands aid in strengthening. Therapists use safe patient-handling equipment and ambulation aids to address gait impairments. Adaptive toileting, dressing, bathing, and feeding tools facilitate greater independence with activities of daily living. Augmentative and alternative communication devices promote well-being and communication of basic needs. Splints prevent joint contracture and maintain functional range of motion. Overall, many rehabilitation devices are safe and feasible for use in an ICU setting and serve to maximize strength and functional independence. The purpose of this narrative review is to discuss the benefits and limitations of available rehabilitation devices in the context of critical illness rehabilitation goals.
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Affiliation(s)
- Katie Koester
- Department of Rehabilitations Services, Froedtert Hospital and the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Heidi Troeller
- Department of Rehabilitations Services, Froedtert Hospital and the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sara Panter
- Department of Rehabilitations Services, Froedtert Hospital and the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Emily Winter
- Department of Rehabilitations Services, Froedtert Hospital and the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jayshil J Patel
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Safety of Patient Mobilization and Rehabilitation in the Intensive Care Unit. Systematic Review with Meta-Analysis. Ann Am Thorac Soc 2018; 14:766-777. [PMID: 28231030 DOI: 10.1513/annalsats.201611-843sr] [Citation(s) in RCA: 214] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Early mobilization and rehabilitation of patients in intensive care units (ICUs) may improve physical function, and reduce the duration of delirium, mechanical ventilation, and ICU length of stay. However, safety concerns are an important barrier to widespread implementation. OBJECTIVES To synthesize safety data regarding patient mobilization and rehabilitation in the ICU, including falls, removal of endotracheal tubes, removal or dysfunction of intravascular catheters, removal of other catheters/tubes, cardiac arrest, hemodynamic changes, and desaturation. DATA SOURCES Systematic literature review, including searches of five databases. Eligible studies evaluated patients who received mobilization-related interventions in the ICU. Exclusion criteria included: (1) case series with fewer than 10 patients; (2) majority of patients under 18 years of age; and (3) data not reported to permit calculation of incidence of safety events. DATA EXTRACTION Number of patients, mobilization/rehabilitation sessions, potential safety events, and events with negative consequences (e.g., requiring intervention or additional therapy). SYNTHESIS Heterogeneity was assessed by I2 statistics, and bias assessed by the Newcastle-Ottawa Scale and Cochrane risk of bias assessment. The literature search identified 20,660 titles. There were 48 eligible publications evaluating 7,546 patients, with 583 potential safety events occurring in 22,351 mobilization/rehabilitation sessions. There was a total of 583 (2.6%) potential safety events with heterogeneity in the definitions for these events. For the safety event types that could be meta-analyzed, pooled incidences per 1,000 mobilization/rehabilitation sessions (95% confidence interval), were: hemodynamic changes, 3.8 (1.3-11.4), and desaturation, 1.9 (0.9-4.3). A total of 24 studies of 3,404 patients reported on any consequences of potential safety events (e.g., needing to increase dose of vasopressor due to mobility-related hypotension), with a frequency of 0.6% in 14,398 mobilization/rehabilitation sessions. CONCLUSIONS Patient mobilization and physical rehabilitation in the ICU appears safe, with a low incidence of potential safety events, and only rare events having any consequences for patient management. Heterogeneity in the definition of safety events across studies emphasizes the importance of implementing existing consensus-based definitions.
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Kim D. Rehabilitation and Intensive Care Unit. Acute Crit Care 2018; 33:43-45. [PMID: 31723859 PMCID: PMC6848999 DOI: 10.4266/acc.2018.00080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Deokkyu Kim
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Hospital, Jeonju, Korea
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Lago AF, de Oliveira AS, de Souza HCD, da Silva JS, Basile-Filho A, Gastaldi AC. The effects of physical therapy with neuromuscular electrical stimulation in patients with septic shock: Study protocol for a randomized cross-over design. Medicine (Baltimore) 2018; 97:e9736. [PMID: 29419665 PMCID: PMC5944671 DOI: 10.1097/md.0000000000009736] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Septic shock is a potentially fatal organ dysfunction caused by an imbalance of the host response to infection. The changes in microcirculation during sepsis can be explained by the alterations in the endothelial barrier function. Endothelial progenitor cells (EPCs) are a potential recovery index of endothelial function and it an increase in response to neuromuscular electrical stimulation (NMES) was demonstrated. Therefore, the objective of this study is to investigate the effects of NMES in patients with septic shock. METHODS AND ANALYSIS It is a study protocol for a randomized cross-over design in an intensive care unit of a tertiary University hospital. Thirty-one patients aged 18 to 65 years. The study will be divided in 2 phases: the phase one will be held in the first 72 hours of septic shock and the phase two after 3 days of first assessment. Patients will be randomly selected to the intervention protocol (decubitus position with the limbs raised and NMES) and control protocol (decubitus position with the limbs raised without NMES). After this procedure, the patients will be allocated in group 1 (intervention and control protocol) or group 2 (control and intervention protocol) with a wash-out period of 4 to 6 hours between them. The main outcome is mobilization of EPCs. The secondary outcome is metabolic and hemodynamic data. A linear mixed model will be used for analysis of dependent variables and estimated values of the mean of the differences of each effect.
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Affiliation(s)
- Alessandra Fabiane Lago
- Department of Physiotherapy, Rehabilitation and Functional Performance Post Graduation Program
| | | | | | | | - Anibal Basile-Filho
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Ada Clarice Gastaldi
- Department of Physiotherapy, Rehabilitation and Functional Performance Post Graduation Program
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Simoneau-Buessinger E, Leteneur S, Bisman A, Gabrielli F, Jakobi J. Ultrasonographic quantification of architectural response in tibialis anterior to neuromuscular electrical stimulation. J Electromyogr Kinesiol 2017; 36:90-95. [DOI: 10.1016/j.jelekin.2017.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 07/25/2017] [Accepted: 07/25/2017] [Indexed: 10/19/2022] Open
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Sommers J, Wieferink DC, Dongelmans DA, Nollet F, Engelbert RHH, van der Schaaf M. Body weight-supported bedside treadmill training facilitates ambulation in ICU patients: An interventional proof of concept study. J Crit Care 2017; 41:150-155. [PMID: 28549273 DOI: 10.1016/j.jcrc.2017.05.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/02/2017] [Accepted: 05/10/2017] [Indexed: 01/03/2023]
Abstract
PURPOSE Early mobilisation is advocated to improve recovery of intensive care unit (ICU) survivors. However, severe weakness in combination with tubes, lines and machinery are practical barriers for the implementation of ambulation with critically ill patients. The aim of this study was to explore the feasibility of Body Weight-Supported Treadmill Training (BWSTT) in critically ill patients in the ICU. METHODS A custom build bedside Body Weight-Supported Treadmill was used and evaluated in medical and surgical patients in the ICU. Feasibility was evaluated according to eligibility, successful number of BWSTT, number of staff needed, adverse events, number of patients that could not have walked without BWSTT, patient satisfaction and anxiety. RESULTS Twenty participants, underwent 54 sessions BWSTT. Two staff members executed the BWSTT and no adverse events occurred. Medical equipment did not have to be disconnected during all treatment sessions. In 74% of the sessions, the participants would not have been able to walk without the BWSTT. Patient satisfaction with BWSTT was high and anxiety low. CONCLUSIONS This proof of concept study demonstrated that BWSTT is safe, reduces staff resource, and facilitates the first time to ambulation in critically ill patients with severe muscle weakness in the ICU.
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Affiliation(s)
- Juultje Sommers
- Department of Rehabilitation medicine, Academic Medical Center (AMC), University of Amsterdam, The Netherlands.
| | - Denise C Wieferink
- Department of Rehabilitation medicine, Academic Medical Center (AMC), University of Amsterdam, The Netherlands.
| | - Dave A Dongelmans
- Department of Intensive Care medicine, Academic Medical Center (AMC), University of Amsterdam, The Netherlands.
| | - Frans Nollet
- Department of Rehabilitation medicine, Academic Medical Center (AMC), University of Amsterdam, The Netherlands.
| | - Raoul H H Engelbert
- Department of Rehabilitation medicine, Academic Medical Center (AMC), University of Amsterdam, The Netherlands; Amsterdam School of Health Professions (ASHP), University of Applied Sciences, Amsterdam, The Netherlands.
| | - Marike van der Schaaf
- Department of Rehabilitation medicine, Academic Medical Center (AMC), University of Amsterdam, The Netherlands; Amsterdam School of Health Professions (ASHP), University of Applied Sciences, Amsterdam, The Netherlands.
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Woo K, Kim J, Kim HB, Choi H, Kim K, Lee D, Na S. The Effect of Electrical Muscle Stimulation and In-bed Cycling on Muscle Strength and Mass of Mechanically Ventilated Patients: A Pilot Study. Acute Crit Care 2017; 33:16-22. [PMID: 31723855 PMCID: PMC6849008 DOI: 10.4266/acc.2017.00542] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 11/30/2022] Open
Abstract
Background Critically ill patients experience muscle weakness, which leads to functional disability. Both functional electrical stimulation (FES) and in-bed cycling can be an alternative measure for intensive care unit (ICU) patients who are not feasible for active exercise. The aim of this study was to examine whether FES and in-bed cycling have a positive effect on muscle mass in ICU patients. Methods Critically ill patients who received mechanical ventilation for at least 24 hours were included. After passive range of motion exercise, in-bed cycling was applied for 20 minutes, and FES was applied for 20 minutes on the left leg. The right leg received in-bed cycling and the left leg received both FES and in-bed cycling. Thigh circumferences and rectus femoris cross-sectional area (CSA) were assessed with ultrasonography before and after the intervention. Muscle strength was assessed by Medical Research Council scale. Results A total of 10 patients were enrolled in this study as a pilot study. Before and after the intervention, the CSA of right rectus femoris increased from 5.08 ± 1.51 cm2 to 6.01 ± 2.21 cm2 , which was statistically significant (P = 0.003). The thigh circumference was also increased and statistically significant (P = 0.006). There was no difference between left and right in regard to FES application. There is no significant change in muscle strength before and after the intervention (right and left, P = 0.317 and P = 0.368, respectively). Conclusions In-bed cycling increased thigh circumferences rectus femoris CSA. Adding FES did not show differences.
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Affiliation(s)
- Kyeongyoon Woo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Bin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyunwoo Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kibum Kim
- Department of Rehabilitation Medicine, Severance Hospital, Seoul, Korea
| | - Donghyung Lee
- Department of Nursing, Severance Hospital, Seoul, Korea
| | - Sungwon Na
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Hodgson CL, Tipping CJ. Physiotherapy management of intensive care unit-acquired weakness. J Physiother 2017; 63:4-10. [PMID: 27989729 DOI: 10.1016/j.jphys.2016.10.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 10/31/2016] [Indexed: 12/11/2022] Open
Abstract
[Hodgson CL, Tipping CJ (2016) Physiotherapy management of intensive care unit-acquired weakness.Journal of Physiotherapy63: 4-10].
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Affiliation(s)
- Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University; The Alfred Hospital, Melbourne, Australia
| | - Claire J Tipping
- Australian and New Zealand Intensive Care Research Centre, Monash University; The Alfred Hospital, Melbourne, Australia
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Kho ME, Molloy AJ, Clarke FJ, Ajami D, McCaughan M, Obrovac K, Murphy C, Camposilvan L, Herridge MS, Koo KKY, Rudkowski J, Seely AJE, Zanni JM, Mourtzakis M, Piraino T, Cook DJ. TryCYCLE: A Prospective Study of the Safety and Feasibility of Early In-Bed Cycling in Mechanically Ventilated Patients. PLoS One 2016; 11:e0167561. [PMID: 28030555 PMCID: PMC5193383 DOI: 10.1371/journal.pone.0167561] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 11/14/2016] [Indexed: 11/30/2022] Open
Abstract
Introduction The objective of this study was to assess the safety and feasibility of in-bed cycling started within the first 4 days of mechanical ventilation (MV) to inform a future randomized clinical trial. Methods We conducted a 33-patient prospective cohort study in a 21-bed adult academic medical-surgical intensive care unit (ICU) in Hamilton, ON, Canada. We included adult patients (≥ 18 years) receiving MV who walked independently pre-ICU. Our intervention was 30 minutes of in-bed supine cycling 6 days/week in the ICU. Our primary outcome was Safety (termination), measured as events prompting cycling termination; secondary Safety (disconnection or dislodgement) outcomes included catheter/tube dislodgements. Feasibility was measured as consent rate and fidelity to intervention. For our primary outcome, we calculated the binary proportion and 95% confidence interval (CI). Results From 10/2013-8/2014, we obtained consent from 34 of 37 patients approached (91.9%), 33 of whom received in-bed cycling. Of those who cycled, 16(48.4%) were female, the mean (SD) age was 65.8(12.2) years, and APACHE II score was 24.3(6.7); 29(87.9%) had medical admitting diagnoses. Cycling termination was infrequent (2.0%, 95% CI: 0.8%-4.9%) and no device dislodgements occurred. Cycling began a median [IQR] of 3 [2, 4] days after ICU admission; patients received 5 [3, 8] cycling sessions with a median duration of 30.7 [21.6, 30.8] minutes per session. During 205 total cycling sessions, patients were receiving invasive MV (150 [73.1%]), vasopressors (6 [2.9%]), sedative or analgesic infusions (77 [37.6%]) and dialysis (4 [2.0%]). Conclusions Early cycling within the first 4 days of MV among hemodynamically stable patients is safe and feasible. Research to evaluate the effect of early cycling on patient function is warranted. Trial Registration Clinicaltrials.gov: NCT01885442
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Affiliation(s)
- Michelle E. Kho
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
- * E-mail:
| | - Alexander J. Molloy
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - France J. Clarke
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Daana Ajami
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Magda McCaughan
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Kristy Obrovac
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Christina Murphy
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Laura Camposilvan
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Margaret S. Herridge
- Department of Medicine, University of Toronto, Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Karen K. Y. Koo
- Swedish Early Mobility Program in Critical Care, First Hill Campus, Swedish Medical Group, Seattle, Washington
- Department of Medicine, Western University, London, Ontario, Canada
| | - Jill Rudkowski
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew J. E. Seely
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Jennifer M. Zanni
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
| | - Marina Mourtzakis
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Thomas Piraino
- Respiratory Therapy Service, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Deborah J. Cook
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Jones S, Man WD, Gao W, Higginson IJ, Wilcock A, Maddocks M. Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease. Cochrane Database Syst Rev 2016; 10:CD009419. [PMID: 27748503 PMCID: PMC6464134 DOI: 10.1002/14651858.cd009419.pub3] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND This review is an update of a previously published review in the Cochrane Database of Systematic Reviews Issue 1, 2013 on Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease.Patients with advanced progressive disease often experience muscle weakness, which can impact adversely on their ability to be independent and their quality of life. In those patients who are unable or unwilling to undertake whole-body exercise, neuromuscular electrical stimulation (NMES) may be an alternative treatment to enhance lower limb muscle strength. Programmes of NMES appear to be acceptable to patients and have led to improvements in muscle function, exercise capacity, and quality of life. However, estimates regarding the effectiveness of NMES based on individual studies lack power and precision. OBJECTIVES Primary objective: to evaluate the effectiveness of NMES on quadriceps muscle strength in adults with advanced disease. Secondary objectives: to examine the safety and acceptability of NMES, and its effect on peripheral muscle function (strength or endurance), muscle mass, exercise capacity, breathlessness, and health-related quality of life. SEARCH METHODS We identified studies from searches of the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR), and Database of Abstracts of Reviews of Effects (DARE) (the Cochrane Library), MEDLINE (OVID), Embase (OVID), CINAHL (EBSCO), and PsycINFO (OVID) databases to January 2016; citation searches, conference proceedings, and previous systematic reviews. SELECTION CRITERIA We included randomised controlled trials in adults with advanced chronic respiratory disease, chronic heart failure, cancer, or HIV/AIDS comparing a programme of NMES as a sole or adjunct intervention to no treatment, placebo NMES, or an active control. We imposed no language restriction. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on study design, participants, interventions, and outcomes. We assessed risk of bias using the Cochrane 'Risk of bias' tool. We calculated mean differences (MD) or standardised mean differences (SMD) between intervention and control groups for outcomes with sufficient data; for other outcomes we described findings from individual studies. We assessed the evidence using GRADE and created a 'Summary of findings' table. MAIN RESULTS Eighteen studies (20 reports) involving a total of 933 participants with COPD, chronic respiratory disease, chronic heart failure, and/or thoracic cancer met the inclusion criteria for this update, an additional seven studies since the previous version of this review. All but one study that compared NMES to resistance training compared a programme of NMES to no treatment or placebo NMES. Most studies were conducted in a single centre and had a risk of bias arising from a lack of participant or assessor blinding and small study size. The quality of the evidence using GRADE comparing NMES to control was low for quadriceps muscle strength, moderate for occurrence of adverse events, and very low to low for all other secondary outcomes. We downgraded the quality of evidence ratings predominantly due to inconsistency among study findings and imprecision regarding estimates of effect. The included studies reported no serious adverse events and a low incidence of muscle soreness following NMES.NMES led to a statistically significant improvement in quadriceps muscle strength as compared to the control (12 studies; 781 participants; SMD 0.53, 95% confidence interval (CI) 0.19 to 0.87), equating to a difference of approximately 1.1 kg. An increase in muscle mass was also observed following NMES, though the observable effect appeared dependent on the assessment modality used (eight studies, 314 participants). Across tests of exercise performance, mean differences compared to control were statistically significant for the 6-minute walk test (seven studies; 317 participants; 35 m, 95% CI 14 to 56), but not for the incremental shuttle walk test (three studies; 434 participants; 9 m, 95% CI -35 to 52), endurance shuttle walk test (four studies; 452 participants; 64 m, 95% CI -18 to 146), or for cardiopulmonary exercise testing with cycle ergometry (six studies; 141 participants; 45 mL/minute, 95% CI -7 to 97). Limited data were available for other secondary outcomes, and we could not determine the most beneficial type of NMES programme. AUTHORS' CONCLUSIONS The overall conclusions have not changed from the last publication of this review, although we have included more data, new analyses, and an assessment of the quality of the evidence using the GRADE approach. NMES may be an effective treatment for muscle weakness in adults with advanced progressive disease, and could be considered as an exercise treatment for use within rehabilitation programmes. Further research is very likely to have an important impact on our confidence in the estimate of effect and may change the estimate. We recommend further research to understand the role of NMES as a component of, and in relation to, existing rehabilitation approaches. For example, studies may consider examining NMES as an adjuvant treatment to enhance the strengthening effect of programmes, or support patients with muscle weakness who have difficulty engaging with existing services.
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Affiliation(s)
- Sarah Jones
- Royal Brompton & Harefield NHS Foundation Trust and Imperial CollegeNIHR Respiratory Biomedical Research UnitLondonUK
- Harefield HospitalHarefield Pulmonary Rehabilitation UnitMiddlesexUK
| | - William D‐C Man
- Royal Brompton & Harefield NHS Foundation Trust and Imperial CollegeNIHR Respiratory Biomedical Research UnitLondonUK
- Harefield HospitalHarefield Pulmonary Rehabilitation UnitMiddlesexUK
| | - Wei Gao
- King's College LondonDepartment of Palliative Care, Policy and Rehabilitation, Cicely Saunders InstituteLondonUK
| | - Irene J Higginson
- King's College LondonDepartment of Palliative Care, Policy and Rehabilitation, Cicely Saunders InstituteLondonUK
| | - Andrew Wilcock
- University of NottinghamHayward House Macmillan Specialist Palliative Care UnitNottingham City Hospital NHS TrustNottinghamUKNG5 1PB
| | - Matthew Maddocks
- Cicely Saunders Institute, King's College LondonDepartment of Palliative Care, Policy and RehabilitationDenmark HillLondonUKSE5 9PJ
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[Algorithms for early mobilization in intensive care units]. Med Klin Intensivmed Notfmed 2016; 112:156-162. [PMID: 27600938 DOI: 10.1007/s00063-016-0210-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/09/2016] [Accepted: 08/12/2016] [Indexed: 10/21/2022]
Abstract
Immobility of patients in intensive care units (ICU) can lead to long-lasting physical and cognitive decline. During the last few years, bundles for rehabilitation were developed, including early mobilization. The German guideline for positioning therapy and mobilization, in general, recommends the development of ICU-specific protocols. The aim of this narrative review is to provide guidance when developing a best practice protocol in one's own field of work. It is recommended to a) implement early mobilization as part of a bundle, including screening and management of patient's awareness, pain, anxiety, stress, delirium and family's presence, b) develop a traffic-light system of specific in- and exclusion criteria in an interprofessional process, c) use checklists to assess risks and preparation of mobilization, d) use the ICU Mobility Scale for targeting and documentation of mobilization, e) use relative safety criteria for hemodynamic and respiratory changes, and Borg Scale for subjective evaluation, f) document and evaluate systematically mobilization levels, barriers, unwanted safety events and other parameters.
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Hashem MD, Parker AM, Needham DM. Early Mobilization and Rehabilitation of Patients Who Are Critically Ill. Chest 2016; 150:722-31. [PMID: 26997241 PMCID: PMC6026260 DOI: 10.1016/j.chest.2016.03.003] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 02/28/2016] [Accepted: 03/01/2016] [Indexed: 11/17/2022] Open
Abstract
Neuromuscular disorders are increasingly recognized as a cause of both short- and long-term physical morbidity in survivors of critical illness. This recognition has given rise to research aimed at better understanding the risk factors and mechanisms associated with neuromuscular dysfunction and physical impairment associated with critical illness, as well as possible interventions to prevent or treat these issues. Among potential risk factors, bed rest is an important modifiable risk factor. Early mobilization and rehabilitation of patients who are critically ill may help prevent or mitigate the sequelae of bed rest and improve patient outcomes. Research studies and quality improvement projects have demonstrated that early mobilization and rehabilitation are safe and feasible in patients who are critically ill, with potential benefits including improved physical functioning and decreased duration of mechanical ventilation, intensive care, and hospital stay. Despite these findings, early mobilization and rehabilitation are still uncommon in routine clinical practice, with many perceived barriers. This review summarizes potential risk factors for neuromuscular dysfunction and physical impairment associated with critical illness, highlights the potential role of early mobilization and rehabilitation in improving patient outcomes, and discusses some of the commonly perceived barriers to early mobilization and strategies for overcoming them.
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Affiliation(s)
- Mohamed D Hashem
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Ann M Parker
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD.
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Coutinho WM, Santos LJD, Fernandes J, Vieira SRR, Forgiarini Junior LA, Dias AS. Efeito agudo da utilização do cicloergômetro durante atendimento fisioterapêutico em pacientes críticos ventilados mecanicamente. FISIOTERAPIA E PESQUISA 2016. [DOI: 10.1590/1809-2950/15549123032016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Pacientes internados em unidades de terapia intensiva (UTI) e ventilados mecanicamente comumente apresentam disfunção muscular devido à inatividade física, à presença de processos inflamatórios e ao uso de agentes farmacológicos. O objetivo deste estudo foi comparar a utilização aguda do cicloergômetro em pacientes críticos ventilados mecanicamente internados em UTI. Trata-se de um ensaio clínico randomizado, no qual foram incluídos 25 pacientes em ventilação mecânica na UTI do Hospital de Clínicas de Porto Alegre. Foram coletadas, pré e pós-intervenção, variáveis hemodinâmicas e respiratórias, bem como foram avaliadas a troca gasosa, por meio da gasometria arterial, os níveis de lactato e proteína C reativa. O protocolo consistiu de diagonais do método de Facilitação Neuromuscular Proprioceptiva de membros superiores e inferiores e técnicas de higiene brônquica, quando necessário. Já no grupo intervenção foi realizado, além da fisioterapia descrita previamente, o cicloergômetro passivo. A análise foi realizada mediante o programa SPSS 18.0. Os dados contínuos foram expressos em média e desvio-padrão, e o nível de significância adotado foi de 5%. Observou-se alteração estatisticamente significativa em relação à pressão de pico (pré: 25,1±5,9; pós: 21,0±2,7cmH2O; p=0,03) no grupo convencional e ao bicarbonato (pré: 23,5±4,3; pós: 20,6±3,0; p=0,002) no grupo intervenção. Concluiu-se que a utilização do cicloergômetro num protocolo de mobilização precoce não altera a mecânica respiratória, nem a hemodinâmica e não resulta em respostas fisiológicas agudas.
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Ten reasons why ICU patients should be mobilized early. Intensive Care Med 2016; 43:86-90. [PMID: 27562244 DOI: 10.1007/s00134-016-4513-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 08/16/2016] [Indexed: 10/21/2022]
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Pope S, Vickerstaff AL, Wareham AP. Lessons learned from early rehabilitation of complex trauma at the Royal Centre for Defence Medicine. J ROY ARMY MED CORPS 2016; 163:124-131. [PMID: 27412360 DOI: 10.1136/jramc-2016-000648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 06/10/2016] [Accepted: 06/14/2016] [Indexed: 02/03/2023]
Abstract
During the recent conflicts in Iraq and Afghanistan, substantial numbers of service personnel survived devastating injuries, presenting significant challenges for early rehabilitation at Queen Elizabeth Hospital Birmingham. Royal Centre for Defence Medicine personnel augmented NHS therapy provision, gaining significant experience in rehabilitating complex trauma. Multidisciplinary working was key to delivering this service, with a unique rehabilitation coordinating officer position established to manage the rehabilitation pathway. A military exercise rehabilitation instructor provided daily gym-based rehabilitation, developing exercise tolerance. Emphasis was placed on early independence, reducing pain, eliminating complications and optimising function. Innovative solutions and non-standard combinations of rehabilitation were required, with therapy working practices redesigned that, we believe, exceed provision elsewhere, including novel applications such as unique patient transfers, specialist seating, additional equipment, problem-solving teaching and early upper limb prosthetic provision. Active pain management allowed engagement in rehabilitation. With limited evidence available, therapeutic modalities attempting to alleviate phantom limb pain centred on patients' ability to engage in treatment. Finally, the requirement to measure change in early trauma rehabilitation was identified, leading to the development of the preprosthetic functional outcome measure. This article aims to document advances made, lessons learned, encourage debate and identify priorities for future research for military complex trauma rehabilitation.
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Affiliation(s)
- Sue Pope
- Directorate of Defence Rehabilitation, DMRC Headley Court, Epsom, UK
| | - A L Vickerstaff
- Defence Primary Healthcare, Wales and West Midlands, Donnington, UK
| | - A P Wareham
- PCRF Leuchars, Leuchars Station Medical Centre, St Andrews, Fife, UK
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Hoyer EH, Friedman M, Lavezza A, Wagner-Kosmakos K, Lewis-Cherry R, Skolnik JL, Byers SP, Atanelov L, Colantuoni E, Brotman DJ, Needham DM. Promoting mobility and reducing length of stay in hospitalized general medicine patients: A quality-improvement project. J Hosp Med 2016; 11:341-7. [PMID: 26849277 DOI: 10.1002/jhm.2546] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 12/05/2015] [Accepted: 12/17/2015] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To determine whether a multidisciplinary mobility promotion quality-improvement (QI) project would increase patient mobility and reduce hospital length of stay (LOS). PATIENTS AND METHODS Implemented using a structured QI model, the project took place between March 1, 2013 and March 1, 2014 on 2 general medicine units in a large academic medical center. There were 3352 patients admitted during the QI project period. The Johns Hopkins Highest Level of Mobility (JH-HLM) scale, an 8-point ordinal scale ranging from bed rest (score = 1) to ambulating ≥250 feet (score = 8), was used to quantify mobility. Changes in JH-HLM scores were compared for the first 4 months of the project (ramp-up phase) versus 4 months after project completion (post-QI phase) using generalized estimating equations. We compared the relative change in median LOS for the project months versus 12 months prior among the QI units, using multivariable linear regression analysis adjusting for 7 demographic and clinically relevant variables. RESULTS Comparing the ramp-up versus post-QI phases, patients reaching JH-HLM's ambulation status increased from 43% to 70% (P < 0.001), and patients with improved JH-HLM mobility scores between admission and discharge increased from 32% to 45% (P < 0.001). For all patients, the QI project was associated with an adjusted median LOS reduction of 0.40 (95% confidence interval [CI]: -0.57 to -0.21, P < 0.001) days compared to 12 months prior. A subgroup of patients expected to have a longer LOS (expected LOS >7 days), were associated with a significantly greater adjusted median reduction in LOS of 1.11 (95% CI: -1.53 to -0.65, P < 0.001) days. Increased mobility was not associated with an increase in injurious falls compared to 12 months prior on the QI units (P = 0.73). CONCLUSIONS AND RELEVANCE Active prevention of a decline in physical function that commonly occurs during hospitalization may be achieved with a structured QI approach. In an adult medicine population, our QI project was associated with improved mobility, and this may have contributed to a reduction in LOS, particularly for more complex patients with longer expected hospital stay. Journal of Hospital Medicine 2016. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Erik H Hoyer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
- Division of General Internal Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Michael Friedman
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
| | - Annette Lavezza
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
| | | | | | - Judy L Skolnik
- Department of Nursing, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sherrie P Byers
- Department of Nursing, Johns Hopkins Hospital, Baltimore, Maryland
| | - Levan Atanelov
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
| | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Daniel J Brotman
- Division of General Internal Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Dale M Needham
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
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Kho ME, Molloy AJ, Clarke F, Herridge MS, Koo KKY, Rudkowski J, Seely AJE, Pellizzari JR, Tarride JE, Mourtzakis M, Karachi T, Cook DJ. CYCLE pilot: a protocol for a pilot randomised study of early cycle ergometry versus routine physiotherapy in mechanically ventilated patients. BMJ Open 2016; 6:e011659. [PMID: 27059469 PMCID: PMC4838736 DOI: 10.1136/bmjopen-2016-011659] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Early exercise with in-bed cycling as part of an intensive care unit (ICU) rehabilitation programme has the potential to improve physical and functional outcomes following critical illness. The objective of this study is to determine the feasibility of enrolling adults in a multicentre pilot randomised clinical trial (RCT) of early in-bed cycling versus routine physiotherapy to inform a larger RCT. METHODS AND ANALYSIS 60-patient parallel group pilot RCT in 7 Canadian medical-surgical ICUs. We will include all previously ambulatory adult patients within the first 0-4 days of mechanical ventilation, without exclusion criteria. After informed consent, patients will be randomised using a web-based, centralised electronic system, to 30 min of in-bed leg cycling in addition to routine physiotherapy, 5 days per week, for the duration of their ICU stay (28 days maximum) or routine physiotherapy alone. We will measure patients' muscle strength (Medical Research Council Sum Score, quadriceps force) and function (Physical Function in ICU Test (scored), 30 s sit-to-stand, 2 min walk test) at ICU awakening, ICU discharge and hospital discharge. Our 4 feasibility outcomes are: (1) patient accrual of 1-2 patients per month per centre, (2) protocol violation rate <20%, (3) outcome measure ascertainment >80% at the 3 time points and (4) blinded outcomes ascertainment >80% at hospital discharge. Hospital outcome assessors are blinded to group assignment, whereas participants, ICU physiotherapists, ICU caregivers, research coordinators and ICU outcome assessors are not blinded to group assignment. We will analyse feasibility outcomes with descriptive statistics. ETHICS AND DISSEMINATION Each participating centre will obtain local ethics approval, and results of the study will be published to inform the design and conduct of a future multicentre RCT of in-bed cycling to improve physical outcomes in ICU survivors. TRIAL REGISTRATION NUMBER NCT02377830; Pre-results.
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Affiliation(s)
- Michelle E Kho
- McMaster University, School of Rehabilitation Science, Hamilton, Ontario, Canada
- Department of Physiotherapy, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander J Molloy
- Department of Physiotherapy, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - France Clarke
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Margaret S Herridge
- Department of Medicine, University of Toronto, Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Karen K Y Koo
- Swedish Early Mobility Program in Critical Care, Swedish Medical Group, First Hill Campus, Seattle, Washington, USA
- Department of Medicine, Western University, London, Ontario, Canada
| | - Jill Rudkowski
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew J E Seely
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Joseph R Pellizzari
- Consultation-Liaison Psychiatry Service, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Ontario, Canada
| | - Jean-Eric Tarride
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Programs for the Assessment of Technology in Health, Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada
| | - Marina Mourtzakis
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Timothy Karachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Darragh AR, Shiyko M, Margulis H, Campo M. Effects of a safe patient handling and mobility program on patient self-care outcomes. Am J Occup Ther 2015; 68:589-96. [PMID: 25184472 DOI: 10.5014/ajot.2014.011205] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE. The aim of this study was to determine the effect of a safe patient handling and mobility (SPHM) program on patient self-care outcomes. METHOD. We used a retrospective cohort design. Data were obtained from the electronic medical records of 1,292 patients receiving inpatient rehabilitation services. Self-care scores from the FIM™ for patients who participated in rehabilitation before implementation of an SPHM program were compared with the scores of patients who participated after implementation of the program. RESULTS. Patients who received inpatient rehabilitation services with an SPHM program were as likely to achieve at least modified independence in self-care as those who received inpatient rehabilitation services without an SPHM program. CONCLUSION. SPHM programs may not affect self-care performance in adults receiving inpatient rehabilitation services. However, more work must be done to define specific and effective methods for integrating patient handling technologies into occupational therapy practice.
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Affiliation(s)
- Amy R Darragh
- Amy R. Darragh, PhD, OTR/L, FAOTA, is Assistant Professor, Division of Occupational Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, 406 Atwell Hall, 453 West 10th Avenue, Columbus, OH 43210;
| | - Mariya Shiyko
- Mariya Shiyko, PhD, is Assistant Professor, Northeastern University, Boston, MA
| | - Heather Margulis
- Heather Margulis, PT, MS, is Associate Director of Rehabilitation Services, Hebrew Rehabilitation Center, Boston, MA
| | - Marc Campo
- Marc Campo, PT, PhD, is Professor, School of Health and Natural Sciences, Mercy College, Dobbs Ferry, NY
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Ambrosino N, Casaburi R, Chetta A, Clini E, Donner CF, Dreher M, Goldstein R, Jubran A, Nici L, Owen CA, Rochester C, Tobin MJ, Vagheggini G, Vitacca M, ZuWallack R. 8th International conference on management and rehabilitation of chronic respiratory failure: the long summaries – part 2. Multidiscip Respir Med 2015. [PMCID: PMC4594967 DOI: 10.1186/s40248-015-0027-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Pasqua F, Nardi I, Provenzano A, Mari A. Weaning from tracheostomy in subjects undergoing pulmonary rehabilitation. Multidiscip Respir Med 2015; 10:35. [PMID: 26629342 PMCID: PMC4666070 DOI: 10.1186/s40248-015-0032-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 10/20/2015] [Indexed: 11/17/2022] Open
Abstract
Background Weaning from tracheostomy has implications in management, quality of life, and costs of ventilated patients. Furthermore, endotracheal cannula removing needs further studies. Aim of this study was the validation of a protocol for weaning from tracheostomy and evaluation of predictor factors of decannulation. Methods Medical records of 48 patients were retrospectively evaluated. Patients were decannulated in agreement with a decannulation protocol based on the evaluation of clinical stability, expiratory muscle strength, presence of tracheal stenosis/granulomas, deglutition function, partial pressure of CO2, and PaO2/FiO2 ratio. These variables, together with underlying disease, blood gas analysis parameters, time elapsed with cannula, comordibity, Barthel index, and the condition of ventilation, were evaluated in a logistic model as predictors of decannulation. Results 63 % of patients were successfully decannulated in agreement with our protocol and no one needed to be re-cannulated. Three variables were significantly associated with the decannulation: no pulmonary underlying diseases (OR = 7.12; 95 % CI 1.2–42.2), no mechanical ventilation (OR = 9.55; 95 % CI 2.1–44.2) and period of tracheostomy ≤10 weeks (OR = 6.5; 95 % CI 1.6–27.5). Conclusions The positive course of decannulated patients supports the suitability of the weaning protocol we propose here. The strong predictive role of three clinical variables gives premise for new studies testing simpler decannulation protocols.
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Affiliation(s)
- Franco Pasqua
- Pulmonary Medicine and Rehabilitation, Villa Delle Querce Hospital, Nemi, Rome Italy ; Pulmonary Rehabilitation, San Raffaele Hospital, Montecompatri, Rome Italy
| | - Ilaria Nardi
- Pulmonary Medicine and Rehabilitation, Villa Delle Querce Hospital, Nemi, Rome Italy
| | - Alessia Provenzano
- Pulmonary Medicine and Rehabilitation, Villa Delle Querce Hospital, Nemi, Rome Italy
| | - Alessia Mari
- Pulmonary Medicine and Rehabilitation, Villa Delle Querce Hospital, Nemi, Rome Italy
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Early Rehabilitation in the Intensive Care Unit. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2015. [DOI: 10.1007/s40141-015-0094-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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dos Santos LJ, de Aguiar Lemos F, Bianchi T, Sachetti A, Dall' Acqua AM, da Silva Naue W, Dias AS, Vieira SRR. Early rehabilitation using a passive cycle ergometer on muscle morphology in mechanically ventilated critically ill patients in the Intensive Care Unit (MoVe-ICU study): study protocol for a randomized controlled trial. Trials 2015; 16:383. [PMID: 26314881 PMCID: PMC4552342 DOI: 10.1186/s13063-015-0914-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 08/17/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patients in Intensive Care Units (ICU) are often exposed to prolonged immobilization which, in turn, plays an important role in neuromuscular complications. Exercise with a cycle ergometer is a treatment option that can be used to improve the rehabilitation of patients on mechanical ventilation (MV) in order to minimize the harmful effects of immobility. METHODS/DESIGN A single-blind randomized controlled trial (the MoVe ICU study) will be conducted to evaluate and compare the effects of early rehabilitation using a bedside cycle ergometer with conventional physical therapy on the muscle morphology of the knee extensors and diaphragm in critical ill patients receiving MV. A total of 28 adult patients will be recruited for this study from among those admitted to the intensive care department at the Hospital de Clínicas de Porto Alegre. Eligible patients will be treated with MV from a period of 24 to 48 h, will have spent maximum of 1 week in hospital and will not exhibit any characteristics restricting lower extremity mobility. These subjects will be randomized to receive either conventional physiotherapy or conventional physiotherapy with an additional cycle ergometer intervention. The intervention will be administered passively for 20 min, at 20 revolutions per minute (rpm), once per day, 7 days a week, throughout the time the patients remain on MV. Outcomes will be cross-sectional quadriceps thickness, length of fascicle, pennation angle of fascicles, thickness of vastus lateralis muscle, diaphragm thickness and excursion of critical ICU patients on MV measured with ultrasound. DISCUSSION The MoVe-ICU study will be the first randomized controlled trial to test the hypothesis that early rehabilitation with a passive cycle ergometer can preserve the morphology of knee extensors and diaphragm in critical patients on MV in ICUs. TRIAL REGISTRATION NCT02300662 (25 November 2014).
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Affiliation(s)
- Laura Jurema dos Santos
- Graduate Program in Health Sciences: Cardiology and Cardiovascular Science, Universidade Federal do Rio Grande do Sul (UFRGS), Rua Dr Pereira Neto, 725 torre 1 ap 902, Tristeza-Porto Alegre, RS, CEP 91920530, Brazil. .,Department of Physical Therapy, Universidade Luterana do Brasil (ULBRA), Canoas, RS, Brazil.
| | - Fernando de Aguiar Lemos
- Graduate Program in Human Movement Science, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.
| | - Tanara Bianchi
- Graduate Program in Respiratory Science, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.
| | - Amanda Sachetti
- Graduate Program in Respiratory Science, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.
| | - Ana Maria Dall' Acqua
- Graduate Program in Health Sciences: Cardiology and Cardiovascular Science, Universidade Federal do Rio Grande do Sul (UFRGS), Rua Dr Pereira Neto, 725 torre 1 ap 902, Tristeza-Porto Alegre, RS, CEP 91920530, Brazil.
| | - Wagner da Silva Naue
- Physical Therapy Service-Intensive Care Unit, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.
| | - Alexandre Simões Dias
- Graduate Program in Human Movement Science, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. .,Graduate Program in Respiratory Science, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. .,Department of Physical Therapy, Universidade Federal do Rio Grande do Sul (UFRGS); Physical Therapy Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.
| | - Silvia Regina Rios Vieira
- Graduate Program in Health Sciences: Cardiology and Cardiovascular Science, Universidade Federal do Rio Grande do Sul (UFRGS), Rua Dr Pereira Neto, 725 torre 1 ap 902, Tristeza-Porto Alegre, RS, CEP 91920530, Brazil. .,School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS); Intensive Care Unit, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.
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Kho ME, Martin RA, Toonstra AL, Zanni JM, Mantheiy EC, Nelliot A, Needham DM. Feasibility and safety of in-bed cycling for physical rehabilitation in the intensive care unit. J Crit Care 2015; 30:1419.e1-5. [PMID: 26318234 DOI: 10.1016/j.jcrc.2015.07.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 06/22/2015] [Accepted: 07/18/2015] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose was to evaluate the feasibility and safety of in-bed cycle ergometry as part of routine intensive care unit (ICU) physical therapist (PT) practice. MATERIALS AND METHODS Between July 1, 2010, and December 31, 2011, we prospectively identified all patients admitted to a 16-bed medical ICU receiving cycling by a PT, prospectively collected data on 12 different potential safety events, and retrospectively conducted a chart review to obtain specific details of each cycling session. RESULTS Six hundred eighty-eight patients received PT interventions, and 181 (26%) received a total of 541 cycling sessions (median [interquartile range {IQR}] cycling sessions per patient, 2 [1-4]). Patients' mean (SD) age was 57 (17) years, and 103 (57%) were male. The median (IQR) time from medical ICU admission to first PT intervention and first cycling session was 2 (1-4) and 4 (2-6) days, respectively, with a median (IQR) cycling session duration of 25 (18-30) minutes. On cycling days, the proportion of patients receiving mechanical ventilation, vasopressor infusions, and continuous renal replacement therapy was 80%, 8%, and 7%, respectively. A single safety event occurred, yielding a 0.2% event rate (95% upper confidence limit, 1.0%). CONCLUSIONS Use of in-bed cycling as part of routine PT interventions in ICU patients is feasible and appears safe. Further study of the potential benefits of early in-bed cycling is needed.
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Affiliation(s)
- Michelle E Kho
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, 21287; School of Rehabilitation Science, McMaster University, Hamilton, ON, L8S 1C7.
| | - Robert A Martin
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Amy L Toonstra
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital; Outcomes After Critical Illness and Surgery, Johns Hopkins University
| | - Jennifer M Zanni
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, 21287; Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital; Outcomes After Critical Illness and Surgery, Johns Hopkins University
| | - Earl C Mantheiy
- Division of Pulmonary & Critical Care Medicine, Johns Hopkins University; Outcomes After Critical Illness and Surgery, Johns Hopkins University
| | - Archana Nelliot
- Division of Pulmonary & Critical Care Medicine, Johns Hopkins University; Outcomes After Critical Illness and Surgery, Johns Hopkins University
| | - Dale M Needham
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, 21287; Division of Pulmonary & Critical Care Medicine, Johns Hopkins University; Outcomes After Critical Illness and Surgery, Johns Hopkins University
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Combining nutrition and exercise to optimize survival and recovery from critical illness: Conceptual and methodological issues. Clin Nutr 2015. [PMID: 26212171 DOI: 10.1016/j.clnu.2015.07.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Survivors of critical illness commonly experience neuromuscular abnormalities, including muscle weakness known as ICU-acquired weakness (ICU-AW). ICU-AW is associated with delayed weaning from mechanical ventilation, extended ICU and hospital stays, more healthcare-related hospital costs, a higher risk of death, and impaired physical functioning and quality of life in the months after ICU admission. These observations speak to the importance of developing new strategies to aid in the physical recovery of acute respiratory failure patients. We posit that to maintain optimal muscle mass, strength and physical function, the combination of nutrition and exercise may have the greatest impact on physical recovery of survivors of critical illness. Randomized trials testing this and related hypotheses are needed. We discussed key methodological issues and proposed a common evaluation framework to stimulate work in this area and standardize our approach to outcome assessments across future studies.
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A quality improvement project sustainably decreased time to onset of active physical therapy intervention in patients with acute lung injury. Ann Am Thorac Soc 2015; 11:1230-8. [PMID: 25167767 DOI: 10.1513/annalsats.201406-231oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
RATIONALE Rehabilitation started early during an intensive care unit (ICU) stay is associated with improved outcomes and is the basis for many quality improvement (QI) projects showing important changes in practice. However, little evidence exists regarding whether such changes are sustainable in real-world practice. OBJECTIVES To evaluate the sustained effect of a quality improvement project on the timing of initiation of active physical therapy intervention in patients with acute lung injury (ALI). METHODS This was a pre-post evaluation using prospectively collected data involving consecutive patients with ALI admitted pre-quality improvement (October 2004-April 2007, n = 120) versus post-quality improvement (July 2009-July 2012, n = 123) from a single medical ICU. MEASUREMENTS AND MAIN RESULTS The primary outcome was time to first active physical therapy intervention, defined as strengthening, mobility, or cycle ergometry exercises. Among ICU survivors, more patients in the post-quality improvement versus pre-quality improvement group received physical therapy in the ICU (89% vs. 24%, P < 0.001) and were able to stand, transfer, or ambulate during physical therapy in the ICU (64% vs. 7%, P < 0.001). Among all patients in the post-quality improvement versus pre-quality improvement group, there was a shorter median (interquartile range) time to first physical therapy (4 [2, 6] vs. 11 d [6, 29], P < 0.001) and a greater median (interquartile range) proportion of ICU days with physical therapy after initiation (50% [33, 67%] vs. 18% [4, 47%], P = 0.003). In multivariable regression analysis, the post-quality improvement period was associated with shorter time to physical therapy (adjusted hazard ratio [95% confidence interval], 8.38 [4.98, 14.11], P < 0.001), with this association significant for each of the 5 years during the post-quality improvement period. The following variables were independently associated with a longer time to physical therapy: higher Sequential Organ Failure Assessment score (0.93 [0.89, 0.97]), higher FiO2 (0.86 [0.75, 0.99] for each 10% increase), use of an opioid infusion (0.47 [0.25, 0.89]), and deep sedation (0.24 [0.12, 0.46]). CONCLUSIONS In this single-site, pre-post analysis of patients with ALI, an early rehabilitation quality improvement project was independently associated with a substantial decrease in the time to initiation of active physical therapy intervention that was sustained over 5 years. Over the entire pre-post period, severity of illness and sedation were independently associated with a longer time to initiation of active physical therapy intervention in the ICU.
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Barriers to early mobility of hospitalized general medicine patients: survey development and results. Am J Phys Med Rehabil 2015; 94:304-12. [PMID: 25133615 DOI: 10.1097/phm.0000000000000185] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Functional status decline commonly accompanies hospitalization making patients vulnerable to complications. Such decline can be mitigated through hospital-based early mobility programs. Success in implementing patient mobility quality improvement processes requires evaluating providers' knowledge, attitudes, and behaviors. DESIGN A cross-sectional, self-administered survey in two different hospital settings was completed by 120 nurses and physical and occupational therapists (rehabilitation therapists, 38; nurses, 82) from six general medicine units. The survey was developed using published guidelines, literature review, and provider meetings and refined through pilot testing. Psychometric properties were assessed, and regression analyses were conducted to examine barriers to early mobility by hospital site, provider discipline, and years of experience. RESULTS Internal consistency reliability, item consistency, and discriminant validity psychometric characteristics were acceptable. In multivariable regression analysis, overall perceived barriers were similar between the two hospitals (P = 0.25) and significantly higher for staff with less experience (P = 0.02) and for nurses vs. rehabilitation therapists (P < 0.001).The survey identified specific barriers common to both nurses and rehabilitation therapists and other barriers that were discipline specific. CONCLUSIONS This novel survey identified important barriers to mobilizing medical inpatients that were similar across two hospital settings. These results can assist with the implementation of quality improvement projects for increasing early hospital-based patient mobility.
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Cameron S, Ball I, Cepinskas G, Choong K, Doherty TJ, Ellis CG, Martin CM, Mele TS, Sharpe M, Shoemaker JK, Fraser DD. Early mobilization in the critical care unit: A review of adult and pediatric literature. J Crit Care 2015; 30:664-72. [PMID: 25987293 DOI: 10.1016/j.jcrc.2015.03.032] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 03/19/2015] [Accepted: 03/28/2015] [Indexed: 11/19/2022]
Abstract
Early mobilization of critically ill patients is beneficial, suggesting that it should be incorporated into daily clinical practice. Early passive, active, and combined progressive mobilizations can be safely initiated in intensive care units (ICUs). Adult patients receiving early mobilization have fewer ventilator-dependent days, shorter ICU and hospital stays, and better functional outcomes. Pediatric ICU data are limited, but recent studies also suggest that early mobilization is achievable without increasing patient risk. In this review, we provide a current and comprehensive appraisal of ICU mobilization techniques in both adult and pediatric critically ill patients. Contraindications and perceived barriers to early mobilization, including cost and health care provider views, are identified. Methods of overcoming barriers to early mobilization and enhancing sustainability of mobilization programs are discussed. Optimization of patient outcomes will require further studies on mobilization timing and intensity, particularly within specific ICU populations.
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Affiliation(s)
- Saoirse Cameron
- Functional Recovery in Critically Ill Children: The "Wee-Cover" Longitudinal Cohort Study; Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study
| | - Ian Ball
- Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Medicine, Western University, London, ON, Canada
| | - Gediminas Cepinskas
- Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Medical Biophysics, Western University, London, ON, Canada
| | - Karen Choong
- Functional Recovery in Critically Ill Children: The "Wee-Cover" Longitudinal Cohort Study; Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Timothy J Doherty
- Functional Recovery in Critically Ill Children: The "Wee-Cover" Longitudinal Cohort Study; Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Physical Medicine and Rehabilitation, Western University, London, ON, Canada
| | - Christopher G Ellis
- Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Medicine, Western University, London, ON, Canada; Medical Biophysics, Western University, London, ON, Canada
| | - Claudio M Martin
- Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Medicine, Western University, London, ON, Canada
| | - Tina S Mele
- Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Surgery, Western University, London, ON, Canada
| | - Michael Sharpe
- Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Anesthesia and Perioperative Medicine, Western University, London, ON, Canada
| | - J Kevin Shoemaker
- Functional Recovery in Critically Ill Children: The "Wee-Cover" Longitudinal Cohort Study; Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Kinesiology, Western University, London, ON, Canada
| | - Douglas D Fraser
- Functional Recovery in Critically Ill Children: The "Wee-Cover" Longitudinal Cohort Study; Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Pediatrics, Western University, London, ON, Canada.
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Pires-Neto RC, Pereira AL, Parente C, Sant'anna GND, Esposito DD, Kimura A, Fu C, Tanaka C. Characterization of the use of a cycle ergometer to assist in the physical therapy treatment of critically ill patients. Rev Bras Ter Intensiva 2015; 25:39-43. [PMID: 23887758 PMCID: PMC4031855 DOI: 10.1590/s0103-507x2013000100008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 02/18/2013] [Indexed: 12/03/2022] Open
Abstract
Objective The objective of this study was to use a cycle ergometer to assess
cardiorespiratory changes during active exercise and to verify patients'
satisfaction with this type of activity. Methods A single intervention involving active lower limb exercise was performed with a
cycle ergometer (without load) for 5 minutes. The following variables were
measured before, during and immediately after exercise: heart rate, blood
pressure, respiratory rate, peripheral oxygen saturation and the Borg dyspnea
scale score. Following the exercise, the patients answered a questionnaire to
evaluate their satisfaction with this type of activity. Results A total of 38 patients (65% male) with a mean age of 48 ± 16 years old
participated in the study. Enrolled patients presented a sequential organ failure
assessment (SOFA) score of 2 (0 - 5 scale). During the exercise, 16% of the
patients used ventilation support and 55% of them were breathing at room air. A
comparison of the initial and final values of the variables indicated increases in
the heart rate (92±17 beats/min vs. 95±18 beats/min; p<0.05), the respiratory
rate (19 ± 8 breaths/min vs. 23±8 breaths/min; p<0.05) and the Borg dyspnea
scale score (1.3±1.8 vs. 2.8±2.2; p<0.05). In addition, 85% of the patients
reported enjoying the activity. Only 25% of the patients reported some discomfort,
and 100% of the patients wanted to repeat this type of activity in future
treatments. Conclusion During the cycle ergometer exercises, minor cardiorespiratory changes were
observed in the patients. The evaluated patients reported high satisfaction with
this type of activity.
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Affiliation(s)
- Ruy Camargo Pires-Neto
- Physical Therapy Service, Central Institute, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo, Brazil.
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Needham DM, Korupolu R. Rehabilitation Quality Improvement in an Intensive Care Unit Setting: Implementation of a Quality Improvement Model. Top Stroke Rehabil 2015; 17:271-81. [DOI: 10.1310/tsr1704-271] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Parry SM, Puthucheary ZA. The impact of extended bed rest on the musculoskeletal system in the critical care environment. EXTREME PHYSIOLOGY & MEDICINE 2015; 4:16. [PMID: 26457181 PMCID: PMC4600281 DOI: 10.1186/s13728-015-0036-7] [Citation(s) in RCA: 160] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 09/30/2015] [Indexed: 04/14/2023]
Abstract
Prolonged immobility is harmful with rapid reductions in muscle mass, bone mineral density and impairment in other body systems evident within the first week of bed rest which is further exacerbated in individuals with critical illness. Our understanding of the aetiology and secondary consequences of prolonged immobilization in the critically ill is improving with recent and ongoing research to establish the cause, effect, and best treatment options. This review aims to describe the current literature on bed rest models for examining immobilization-induced changes in the musculoskeletal system and pathophysiology of immobilisation in critical illness including examination of intracellular signalling processes involved. Finally, the review examines the current barriers to early activity and mobilization and potential rehabilitation strategies, which are being, investigated which may reverse the effects of prolonged bed rest. Addressing the deleterious effects of immobilization is a major step in treatment and prevention of the public health issue, that is, critical illness survivorship.
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Affiliation(s)
- Selina M. Parry
- />Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Level 7 Alan Gilbert Building, Parkville, Melbourne, VIC 3010 Australia
| | - Zudin A. Puthucheary
- />Division of Respiratory and Critical Care Medicine, National University Health System, Singapore, Singapore
- />Institute of Health and Human Performance, University College London, London, UK
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Ponfick M, Bösl K, Lüdemann-Podubecka J, Neumann G, Pohl M, Nowak DA, Gdynia HJ. [Intensive care unit acquired weakness. Pathogenesis, treatment, rehabilitation and outcome]. DER NERVENARZT 2014; 85:195-204. [PMID: 24463649 DOI: 10.1007/s00115-013-3958-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The diagnosis of intensive care unit acquired weakness (ICUAW) in the setting of neurological rehabilitation is steadily increasing. This is due to the fact that the intensive care of patients with sepsis or after cardiac or abdominal surgery is improving. A longer duration of respiratory weaning and comorbidities frequently complicate rehabilitation. Clinically, patients present with a flaccid (tetra) paresis and electrophysiological studies have shown axonal damage. Besides involvement of peripheral nerves, muscle can also be affected (critical illness myopathy) leading to ICUAW with inconstant myopathic damage patterns found by electrophysiological testing. Mixed forms can also be found. A specific therapy for ICUAW is not available. Early mobilization to be initiated on the intensive care unit and commencing neurological rehabilitation improve the outcome of ICUAW. This review highlights the current literature regarding the etiology and diagnosis of ICUAW. Furthermore, studies about rehabilitation and outcome of ICUAW are discussed.
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Affiliation(s)
- M Ponfick
- Klinik Kipfenberg GmbH, Kindinger Str. 13, 85110, Kipfenberg, Deutschland,
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Nessizius S. [Physiotherapy in intensive care medicine]. Med Klin Intensivmed Notfmed 2014; 109:547-54. [PMID: 25125235 DOI: 10.1007/s00063-014-0399-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 04/21/2014] [Accepted: 04/28/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND A high amount of recently published articles and reviews have already focused on early mobilisation in intensive care medicine. However, in the clinical setting the problem of its practicability remains as each professional group in the mobility team has its own expectations concerning the interventions made by physiotherapy. Even though there are as yet no standard operation procedures (SOP), there do exist distinctive mobilisation concepts that are well implemented in certain intensive care units (http://www.fruehmobilisierung.de/Fruehmobilisierung/Algorithmen.html). AIM Due to these facts and the urgent need for SOPs this article presents the physiotherapeutic concept for the treatment of patients in the intensive care unit which has been developed by the author: First the patients' respiratory and motor functions have to be established in order to classify the patients and allocate them to their appropriate group (one out of three) according to their capacities; additionally, the patients are analysed by checking their so-called "surrounding conditions". Following these criteria a therapy regime is developed and patients are treated accordingly. By constant monitoring and re-evaluation of the treatment in accordance with the functions of the patient a dynamic system evolves. "Keep it simple" is one of the key features of that physiotherapeutic concept. Thus, a manual for the classification and the physiotherapeutic treatment of an intensive care patient was developed. METHODS In this article it is demonstrated how this concept can be implemented in the daily routine of an intensive care unit. Physiotherapy in intensive care medicine has proven to play an important role in the patients' early rehabilitation if the therapeutic interventions are well adjusted to the needs of the patients. A team of nursing staff, physiotherapists and medical doctors from the core facility for medical intensive care and emergency medicine at the medical university of Innsbruck developed the "Mobilisation Concept for the Multidisciplinary Treatment of the Intensive Care Patient" following the principles of the physiotherapeutic concept mentioned above and published it online on the homepage of the German network for early mobilisation (http://www.fruehmobilisierung.de/Fruehmobilisierung/Algorithmen.html) in spring 2012. The biggest challenge was to find one common language for all professional groups to define the aims of mobilisation. RESULTS The success of the implementation becomes apparent in a well structured and coordinated procedure of early mobilisation, as all partners of the rehabilitation team apply adequate treatments. As a result the patients receive the appropriate treatment at the appropriate time which greatly supports their convalescence.
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Affiliation(s)
- S Nessizius
- Gemeinsame Einrichtung für Intensiv- und Notfallmedizin des Departments Innere Medizin, Universitätskliniken Innsbruck, Anichstraße 34, 6020, Innsbruck, Deutschland,
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Wageck B, Nunes GS, Silva FL, Damasceno MCP, de Noronha M. Application and effects of neuromuscular electrical stimulation in critically ill patients: systematic review. Med Intensiva 2014; 38:444-54. [PMID: 25060511 DOI: 10.1016/j.medin.2013.12.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 11/28/2013] [Accepted: 12/08/2013] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To investigate the applications and effects of neuromuscular electrical stimulation (NMES) in critically ill patients in ICU by means of a systematic review. MATERIALS AND METHODS Electronic searches were conducted in the databases Medline, CINAHL, Cochrane Central Register of Controlled Trials, Web of Science, Embase, ProQuest Health and Medical Complete, AMED, and PEDro. The PEDro score was used to assess the methodological quality of the eligible studies. RESULTS The search yielded a total of 9759 titles and nine articles satisfied the eligibility criteria. These studies showed that NMES can maintain or increase muscle mass, strength and volume, reduce time in mechanical ventilation and weaning time, and increase muscle degradation in critically ill patients in ICU. Two studies allowed a meta-analysis of the effects of NMES on quadriceps femoris strength and it showed a significant effect in favor of NMES in the Medical Research Council (MRC) Scale (standardized mean difference 0.77 points; p=0.02; 95% CI: 0.13-1.40). CONCLUSIONS The selected studies showed that NMES has good results when used for the maintenance of muscle mass and strength in critically ill patients in ICU. Future studies with high methodological quality should be conducted to provide more evidence for the use of NMES in an ICU setting.
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Affiliation(s)
- B Wageck
- Department of Physiotherapy, Center of Health and Sport Sciences, Santa Catarina State University, Florianópolis, Brazil.
| | - G S Nunes
- Department of Physiotherapy, Center of Health and Sport Sciences, Santa Catarina State University, Florianópolis, Brazil
| | - F L Silva
- Santa Casa de Misericórdia Dona Carolina Malheiros, São João da Boa Vista, Brazil
| | - M C P Damasceno
- Santa Casa de Misericórdia Dona Carolina Malheiros, São João da Boa Vista, Brazil
| | - M de Noronha
- Department of Physiotherapy, Center of Health and Sport Sciences, Santa Catarina State University, Florianópolis, Brazil; Department of Allied Health, La Trobe University, Bendigo, Australia
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Safety of physical therapy interventions in critically ill patients: A single-center prospective evaluation of 1110 intensive care unit admissions. J Crit Care 2014; 29:395-400. [DOI: 10.1016/j.jcrc.2013.12.012] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 12/19/2013] [Accepted: 12/22/2013] [Indexed: 01/04/2023]
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Winkelman C, Johnson KD, Gordon N. Associations between muscle-related cytokines and selected patient outcomes in the ICU. Biol Res Nurs 2014; 17:125-34. [PMID: 24875632 DOI: 10.1177/1099800414532709] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Systemic cytokines produced by contracting skeletal muscles may affect the onset and severity of intensive care unit (ICU)-acquired weakness after critical illness. AIMS The purpose of this research was to determine the serum levels of interleukin (IL)-8, IL-15, and tumor necrosis factor-α (TNF-α) among patients receiving mechanical ventilation for >48 hr and examine the relationships of these myokines to outcomes of patient delirium, muscle strength, activities of daily living (ADLs), duration of mechanical ventilation, and length of ICU stay. METHODS In this exploratory, repeated-measures interventional study, the 36 participants received 20 min of once-daily in-bed or out-of-bed activity using an established early progressive mobility protocol after physiologic stability had been demonstrated for >4 hr in the ICU. Blood samples were drawn on 3 consecutive days, beginning on the day of study enrollment, for serum cytokine quantification. RESULTS IL-8, IL-15, and TNF-α were highly variable and consistently elevated in participants compared to normal healthy adults. About 1/3 of participants were positive for significant muscle weakness at discharge from ICU. Repeated values of mean postactivity IL-8 serum values were significantly associated only with ADL following ICU discharge. There were no significant associations with repeated values of mean postactivity IL-15 or TNF-α serum values and outcomes. CONCLUSION Results provide preliminary data for exploring the potential effects of elevated serum values IL-8 and IL-15 in muscle health and TNF-α for muscle damage, including effect sizes to calculate the sample sizes needed for future studies.
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Affiliation(s)
- Chris Winkelman
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Kimberly D Johnson
- Veterans Affairs National Quality Scholars Fellowship Program at the Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA University of Cincinnati School of Nursing, Cincinnati, Ohio
| | - Nahida Gordon
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
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Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med 2014; 9:277-82. [PMID: 24616216 PMCID: PMC4347875 DOI: 10.1002/jhm.2152] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 12/18/2013] [Accepted: 12/23/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine whether functional status near the time of discharge from acute care hospitalization is associated with acute care readmission. PATIENTS AND METHODS Retrospective cohort study of 9405 consecutive patients admitted from an acute care hospital to an inpatient rehabilitation facility between July 1, 2006 and December 31, 2012. Patients' functional status at admission to the rehabilitation facility was assessed by the Functional Independence Measure (FIM) score, and divided into low, middle, or high functional status. The main outcome was readmission to an acute care hospital within 30 days of acute care discharge (for all patients and by subgroup according to diagnostic group: medical, orthopedic, or neurologic). RESULTS There were 1182 (13%) readmissions. FIM score was significantly associated with readmission, with adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for low and middle versus high FIM score category of 3.0 (2.5-3.6; P < 0.001) and 1.5 (95% CI: 1.3-1.8; P < 0.001), respectively. This relationship between FIM score and readmission held across diagnostic category. Medical patients with low functional status had the highest readmission rate (OR: 29%; 95% CI: 25%-32%) and an adjusted OR for readmission of 3.2 (95% CI: 2.4-4.3, P < 0.001) compared to medical patients with high FIM scores. CONCLUSIONS AND RELEVANCE For patients admitted to an acute inpatient rehabilitation facility, functional status near the time of discharge from an acute care hospital is strongly associated with acute care readmission, particularly for medical patients with greater functional impairments. Reducing functional status decline during acute care hospitalization may be an important strategy to lower readmissions.
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Affiliation(s)
- Erik H. Hoyer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
- Address for correspondence and reprint requests: Erik H. Hoyer, MD, 600 N Wolfe Street, Phipps 174, Baltimore, MD 21287; Telephone: 410-502-2438; Fax: 410-502-2419;
| | - Dale M. Needham
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
| | - Levan Atanelov
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
| | - Brenda Knox
- Department of Physical Medicine and Rehabilitation, MedStar Health System, Baltimore, Maryland
| | - Michael Friedman
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
| | - Daniel J. Brotman
- Division of General Internal Medicine, Johns Hopkins University, Baltimore, Maryland
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