1
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Jones JRA, Karahalios A, Puthucheary ZA, Berry MJ, Files DC, Griffith DM, McDonald LA, Morris PE, Moss M, Nordon-Craft A, Walsh T, Berney S, Denehy L. Responsiveness of Critically Ill Adults With Multimorbidity to Rehabilitation Interventions: A Patient-Level Meta-Analysis Using Individual Pooled Data From Four Randomized Trials. Crit Care Med 2023; 51:1373-1385. [PMID: 37246922 DOI: 10.1097/ccm.0000000000005936] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To explore if patient characteristics (pre-existing comorbidity, age, sex, and illness severity) modify the effect of physical rehabilitation (intervention vs control) for the coprimary outcomes health-related quality of life (HRQoL) and objective physical performance using pooled individual patient data from randomized controlled trials (RCTs). DATA SOURCES Data of individual patients from four critical care physical rehabilitation RCTs. STUDY SELECTION Eligible trials were identified from a published systematic review. DATA EXTRACTION Data sharing agreements were executed permitting transfer of anonymized data of individual patients from four trials to form one large, combined dataset. The pooled trial data were analyzed with linear mixed models fitted with fixed effects for treatment group, time, and trial. DATA SYNTHESIS Four trials contributed data resulting in a combined total of 810 patients (intervention n = 403, control n = 407). After receiving trial rehabilitation interventions, patients with two or more comorbidities had HRQoL scores that were significantly higher and exceeded the minimal important difference at 3 and 6 months compared with the similarly comorbid control group (based on the Physical Component Summary score (Wald test p = 0.041). Patients with one or no comorbidities who received intervention had no HRQoL outcome differences at 3 and 6 months when compared with similarly comorbid control patients. No patient characteristic modified the physical performance outcome in patients who received physical rehabilitation. CONCLUSIONS The identification of a target group with two or more comorbidities who derived benefits from the trial interventions is an important finding and provides direction for future investigations into the effect of rehabilitation. The multimorbid post-ICU population may be a select population for future prospective investigations into the effect of physical rehabilitation.
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Affiliation(s)
- Jennifer R A Jones
- Physiotherapy Department, The University of Melbourne, Parkville, Victoria, Australia
- Physiotherapy Department, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia
- Institute of Breathing and Sleep, Heidelberg, Victoria, Australia
| | - Amalia Karahalios
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Zudin A Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, England, United Kingdom
- Adult Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, England, United Kingdom
| | - Michael J Berry
- Department of Health and Exercise Science, Wake Forest University, Winston Salem, NC
| | - D Clark Files
- Pulmonary, Critical Care, Allergy and Immunologic Disease, Wake Forest University, Winston-Salem, NC
- Wake Forest Critical Illness Injury and Recovery Research Center, Wake Forest University, Winston Salem, NC
| | - David M Griffith
- Deanery of Molecular, Genetic and Population Health Sciences, The University of Edinburgh, Edinburgh, United Kingdom
- Royal Infirmary of Edinburgh, NHS (National Health Service) Lothian, Edinburgh, Scotland, United Kingdom
| | - Luke A McDonald
- Physiotherapy Department, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia
| | - Peter E Morris
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Amy Nordon-Craft
- Physical Therapy Program, University of Colorado School of Medicine, Aurora, CO
| | - Timothy Walsh
- Deanery of Molecular, Genetic and Population Health Sciences, The University of Edinburgh, Edinburgh, United Kingdom
- Anaesthetics, Critical Care, and Pain Medicine, School of Clinical Sciences, Queens Medical Research Institute, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Sue Berney
- Physiotherapy Department, The University of Melbourne, Parkville, Victoria, Australia
- Physiotherapy Department, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia
| | - Linda Denehy
- Physiotherapy Department, The University of Melbourne, Parkville, Victoria, Australia
- Melbourne School of Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
- Allied Health, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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2
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Mina DS, Tandon P, Kow AWC, Chan A, Edbrooke L, Raptis DA, Spiro M, Selzner N, Denehy L. The role of acute in-patient rehabilitation on short-term outcomes after liver transplantation: A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14706. [PMID: 35546523 DOI: 10.1111/ctr.14706] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/19/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The indication and surgical complexity of orthotopic liver transplantation underscore the need for strategies to optimize the recovery for transplant recipients. We conducted a systematic review aimed at identifying, evaluating, and synthesizing the evidence examining the effect of in-patient rehabilitation for liver transplant recipients and provide related practice recommendations. METHODS Health research databases were systematically reviewed for studies that included adults who received liver transplantation and participated in acute, post-transplant rehabilitation. Postoperative morbidity, mortality, length of hospital stay, length of intensive care unit stay, and other markers of surgical recovery were extracted. Practice recommendations are provided by an international panel using GRADE. RESULTS Twelve studies were included in the review (including 3901 participants). Rehabilitation interventions varied widely in design and composition; however, details regarding intervention delivery were poorly described in general. The quality of evidence was rated as very low largely owing to "very serious" imprecision, poor reporting, and limited data from comparative studies. Overall, the studies suggest that in-patient rehabilitation for recipients of liver transplantation is safe, tolerable, and feasible, and may benefit functional outcomes. CONCLUSION Two practice recommendations related to in-patient rehabilitation following LT were yielded from this review: (1) it is safe, tolerable, and feasible; and (2) it improves postoperative functional outcomes. Each of the recommendations are weak and supported by low quality of evidence. No recommendation could be made related to benefits or harms for clinical, physiological, and other outcomes. Adequately powered and high quality randomized controlled trials are urgently needed in this area.
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Affiliation(s)
- Daniel Santa Mina
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Puneeta Tandon
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Alfred Wei Chieh Kow
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Liver Transplantation Program, National University Center for Organ Transplantation, National University Health System Singapore, Singapore, Singapore
| | - Albert Chan
- Division of Liver Transplantation, Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - Lara Edbrooke
- Peter MacCallum Cancer Centre, Victoria, Australia
- Department of Physiotherapy, University of Melbourne, Melbourne, Australia
| | - Dimitri Aristotle Raptis
- Division of Surgery & Interventional Science, University College London, London, UK
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Michael Spiro
- Division of Surgery & Interventional Science, University College London, London, UK
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK
| | - Nazia Selzner
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Linda Denehy
- Peter MacCallum Cancer Centre, Victoria, Australia
- Department of Physiotherapy, University of Melbourne, Melbourne, Australia
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3
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Flower L, Haines RW, McNelly A, Bear DE, Koelfat K, Damink SO, Hart N, Montgomery H, Prowle JR, Puthucheary Z. Effect of intermittent or continuous feeding and amino acid concentration on urea-to-creatinine ratio in critical illness. JPEN J Parenter Enteral Nutr 2021; 46:789-797. [PMID: 34462921 DOI: 10.1002/jpen.2258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND We sought to determine whether peaks in essential amino acid (EAA) concentration associated with intermittent feeding may provide anabolic advantages when compared with continuous feeding regimens in critical care. METHODS We performed a secondary analysis of data from a multicenter trial of UK intensive care patients randomly assigned to intermittent or continuous feeding. A linear mixed-effects model was developed to assess differences in urea-creatinine ratio (raised values of which can be a marker of muscle wasting) between arms. To investigate metabolic phenotypes, we performed k-means urea-to-creatinine ratio trajectory clustering. Amino acid concentrations were also modeled against urea-to-creatinine ratio from day 1 to day 7. The main outcome measure was serum urea-to-creatinine ratio (millimole per millimole) from day 0 to the end of the 10-day study period. RESULTS Urea-to-creatinine ratio trajectory differed between feeding regimens (coefficient -.245; P = .002). Patients receiving intermittent feeding demonstrated a flatter urea-to-creatinine ratio trajectory. With k-means analysis, the cluster with the largest proportion of continuously fed patients demonstrated the steepest rise in urea-to-creatinine ratio. Neither protein intake per se nor serum concentrations of EAA concentrations were correlated with urea-to-creatinine ratio (coefficient = .088 [P = .506] and coefficient <.001 [P = .122], respectively). CONCLUSION Intermittent feeding can mitigate the rise in urea-to-creatinine ratio otherwise seen in those continuously fed, suggesting that catabolism may have been, to some degree, prevented.
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Affiliation(s)
- Luke Flower
- William Harvey Research Institute, Queen Mary University of London, London, UK.,Department of Anaesthesia, University College Hospital, London, UK
| | - Ryan W Haines
- William Harvey Research Institute, Queen Mary University of London, London, UK.,Department of Anaesthesia, University College Hospital, London, UK
| | - Angela McNelly
- William Harvey Research Institute, Queen Mary University of London, London, UK.,University College London (UCL), London, UK.,UCL Hospitals NHS Foundation Trust (UCLH), National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), London, UK
| | - Danielle E Bear
- Department of Nutrition and Dietetics St Thomas' NHS Foundation Trust, London, UK.,Department of Critical Care, Guy's and St Thomas' NHS Foundation & King's College London (KCL) NIHR BRC, London, UK.,Centre for Human and Applied Physiological Sciences, Kings College London, London, UK
| | - Kiran Koelfat
- Department of Surgery and School of Nutrition and Translational Research in Metabolism (NUTRIM), University of Maastricht, Maastricht, The Netherlands
| | - Steven Olde Damink
- Department of Surgery and School of Nutrition and Translational Research in Metabolism (NUTRIM), University of Maastricht, Maastricht, The Netherlands.,Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Nicholas Hart
- Centre for Human and Applied Physiological Sciences, Kings College London, London, UK.,Lane Fox Clinical Respiratory Physiology Research Centre Guy's and St. Thomas' NHS Foundation & King's College London (KCL) NIHR BRC, London, UK
| | - Hugh Montgomery
- University College London (UCL), London, UK.,UCL Hospitals NHS Foundation Trust (UCLH), National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), London, UK
| | - John R Prowle
- William Harvey Research Institute, Queen Mary University of London, London, UK.,Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, London, UK.,Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Zudin Puthucheary
- William Harvey Research Institute, Queen Mary University of London, London, UK.,Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
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4
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Mobilization During Critical Illness: A Higher Level of Mobilization Improves Health Status at 6 Months, a Secondary Analysis of a Prospective Cohort Study. Crit Care Med 2021; 49:e860-e869. [PMID: 33967203 DOI: 10.1097/ccm.0000000000005058] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To determine the influence of active mobilization during critical illness on health status in survivors 6 months post ICU admission. DESIGN Post hoc secondary analysis of a prospective cohort study conducted between November 2013 and March 2015. SETTING Two tertiary hospital ICU's in Victoria, Australia. PATIENTS Of 194 eligible patients admitted, mobility data for 186 patients were obtained. Inclusion and exclusion criteria were as per the original trial. INTERVENTIONS The dosage of mobilization in ICU was measured by 1) the Intensive Care Mobility Scale where a higher Intensive Care Mobility Scale level was considered a higher intensity of mobilization or 2) the number of active mobilization sessions performed during the ICU stay. The data were extracted from medical records and analyzed against Euro-quality of life-5D-5 Level version answers obtained from phone interviews with survivors 6 months following ICU admission. The primary outcome was change in health status measured by the Euro-quality of life-5D-5 Level utility score, with change in Euro-quality of life-5D-5 Level mobility domain a secondary outcome. MEASUREMENTS AND MAIN RESULTS Achieving higher levels of mobilization (as per the Intensive Care Mobility Scale) was independently associated with improved outcomes at 6 months (Euro-quality of life-5D-5 Level utility score unstandardized regression coefficient [β] 0.022 [95% CI, 0.002-0.042]; p = 0.033; Euro-quality of life-5D-5 Level mobility domain β = 0.127 [CI, 0.049-0.205]; p = 0.001). Increasing the number of active mobilization sessions was not found to independently influence health status. Illness severity, total comorbidities, and admission diagnosis also independently influenced health status. CONCLUSIONS In critically ill survivors, achieving higher levels of mobilization, but not increasing the number of active mobilization sessions, improved health status 6 months after ICU admission.
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5
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Puthucheary ZA, Gensichen JS, Cakiroglu AS, Cashmore R, Edbrooke L, Heintze C, Neumann K, Wollersheim T, Denehy L, Schmidt KFR. Implications for post critical illness trial design: sub-phenotyping trajectories of functional recovery among sepsis survivors. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:577. [PMID: 32977833 PMCID: PMC7517819 DOI: 10.1186/s13054-020-03275-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/04/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients who survive critical illness suffer from a significant physical disability. The impact of rehabilitation strategies on health-related quality of life is inconsistent, with population heterogeneity cited as one potential confounder. This secondary analysis aimed to (1) examine trajectories of functional recovery in critically ill patients to delineate sub-phenotypes and (2) to assess differences between these cohorts in both clinical characteristics and clinimetric properties of physical function assessment tools. METHODS Two hundred ninety-one adult sepsis survivors were followed-up for 24 months by telephone interviews. Physical function was assessed using the Physical Component Score (PCS) of the Short Form-36 Questionnaire (SF-36) and Activities of Daily Living and the Extra Short Musculoskeletal Function Assessment (XSFMA-F/B). Longitudinal trajectories were clustered by factor analysis. Logistical regression analyses were applied to patient characteristics potentially determining cluster allocation. Responsiveness, floor and ceiling effects and concurrent validity were assessed within clusters. RESULTS One hundred fifty-nine patients completed 24 months of follow-up, presenting overall low PCS scores. Two distinct sub-cohorts were identified, exhibiting complete recovery or persistent impairment. A third sub-cohort could not be classified into either trajectory. Age, education level and number of co-morbidities were independent determinants of poor recovery (AUROC 0.743 ((95%CI 0.659-0.826), p < 0.001). Those with complete recovery trajectories demonstrated high levels of ceiling effects in physical function (PF) (15%), role physical (RP) (45%) and body pain (BP) (57%) domains of the SF-36. Those with persistent impairment demonstrated high levels of floor effects in the same domains: PF (21%), RP (71%) and BP (12%). The PF domain demonstrated high responsiveness between ICU discharge and at 6 months and was predictive of a persistent impairment trajectory (AUROC 0.859 (95%CI 0.804-0.914), p < 0.001). CONCLUSIONS Within sepsis survivors, two distinct recovery trajectories of physical recovery were demonstrated. Older patients with more co-morbidities and lower educational achievements were more likely to have a persistent physical impairment trajectory. In regard to trajectory prediction, the PF score of the SF-36 was more responsive than the PCS and could be considered for primary outcomes. Future trials should consider adaptive trial designs that can deal with non-responders or sub-cohort specific outcome measures more effectively.
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Affiliation(s)
- Zudin A Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK. .,Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK.
| | - Jochen S Gensichen
- Institute of General Practice and Family Medicine, Jena University Hospital, Jena, Germany.,Institute of Family Medicine, University Hospital of the Ludwig Maximilian University, Munich, Germany.,Center of Sepsis Care and Control, Jena University Hospital, Jena, Germany
| | | | - Richard Cashmore
- Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, UK
| | - Lara Edbrooke
- Physiotherapy Department, The University of Melbourne, Melbourne, Australia.,Allied Health Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Christoph Heintze
- Institute of General Practice and Family Medicine, Charité University Medicine Berlin, Berlin, Germany
| | - Konrad Neumann
- Institute of Biometry and Clinical Epidemiology, Charité University Medicine Berlin, Berlin, Germany
| | - Tobias Wollersheim
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité University Medicine Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Linda Denehy
- Physiotherapy Department, The University of Melbourne, Melbourne, Australia.,Allied Health Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Konrad F R Schmidt
- Institute of General Practice and Family Medicine, Jena University Hospital, Jena, Germany.,Center of Sepsis Care and Control, Jena University Hospital, Jena, Germany.,Institute of General Practice and Family Medicine, Charité University Medicine Berlin, Berlin, Germany
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6
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Searching for the Responder, Unpacking the Physical Rehabilitation Needs of Critically Ill Adults: A REVIEW. J Cardiopulm Rehabil Prev 2020; 40:359-369. [PMID: 32956134 DOI: 10.1097/hcr.0000000000000549] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Survivors of critical illness can experience persistent deficits in physical function and poor health-related quality of life and utilize significant health care resources. Short-term improvements in these outcomes have been reported following physical rehabilitation. Safety and feasibility of delivering physical rehabilitation are established; however, low physical activity levels are observed throughout the recovery of patients. We provide examples on how physical activity may be increased through interdisciplinary models of service delivery. Recently, however, there has been an emergence of large randomized controlled trials reporting no effect on long-term patient outcomes. In this review, we use a proposed theoretical construct to unpack the findings of 12 randomized controlled trials that delivered physical rehabilitation during the acute hospital stay. We describe the search for the responder according to modifiers of treatment effect for physical function, health-related quality of life, and health care utilization outcomes. In addition, we propose tailoring and timing physical rehabilitation interventions to patient subgroups that may respond differently based on their impairments and perpetuating factors that hinder recovery. We examine in detail the timing, components, and dosage of the trial intervention arms. We also describe facilitators and barriers to physical rehabilitation implementation and factors that are influential in recovery from critical illness. Through this theoretical construct, we anticipate that physical rehabilitation programs can be better tailored to the needs of survivors to deliver appropriate interventions to patients who derive greatest benefit optimally timed in their recovery trajectory.
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7
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Polastri M, Nava S, Clini E, Vitacca M, Gosselink R. COVID-19 and pulmonary rehabilitation: preparing for phase three. Eur Respir J 2020; 55:55/6/2001822. [PMID: 32586841 PMCID: PMC7401308 DOI: 10.1183/13993003.01822-2020] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 05/19/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Massimiliano Polastri
- Medical Dept of Continuity of Care and Disability, Physical Medicine and Rehabilitation, St Orsola University Hospital, Bologna, Italy
| | - Stefano Nava
- Dept of Clinical, Integrated and Experimental Medicine (DIMES), University of Bologna, Bologna, Italy.,Respiratory and Critical Care Unit, St Orsola University Hospital, Bologna, Italy
| | - Enrico Clini
- University Hospital of Modena Policlinico, Respiratory Diseases Unit, Dept of Medical and Surgical Sciences SMECHIMAI, University of Modena Reggio-Emilia, Modena, Italy
| | - Michele Vitacca
- Respiratory Rehabilitation Dept, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Rik Gosselink
- Dept of Critical Care, University Hospital Leuven, Leuven, Belgium.,Dept of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
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8
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Jones JRA, Berney S, Berry MJ, Files DC, Griffith DM, McDonald LA, Morris PE, Moss M, Nordon-Craft A, Walsh T, Gordon I, Karahalios A, Puthucheary Z, Denehy L. Response to physical rehabilitation and recovery trajectories following critical illness: individual participant data meta-analysis protocol. BMJ Open 2020; 10:e035613. [PMID: 32371516 PMCID: PMC7223158 DOI: 10.1136/bmjopen-2019-035613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 03/20/2020] [Accepted: 03/27/2020] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION The number of inconclusive physical rehabilitation randomised controlled trials for patients with critical illness is increasing. Evidence suggests critical illness patient subgroups may exist that benefit from targeted physical rehabilitation interventions that could improve their recovery trajectory. We aim to identify critical illness patient subgroups that respond to physical rehabilitation and map recovery trajectories according to physical function and quality of life outcomes. Additionally, the utilisation of healthcare resources will be examined for subgroups identified. METHODS AND ANALYSIS This is an individual participant data meta-analysis protocol. A systematic literature review was conducted for randomised controlled trials that delivered additional physical rehabilitation for patients with critical illness during their acute hospital stay, assessed chronic disease burden, with a minimum follow-up period of 3 months measuring performance-based physical function and health-related quality of life outcomes. From 2178 records retrieved in the systematic literature review, four eligible trials were identified by two independent reviewers. Principal investigators of eligible trials were invited to contribute their data to this individual participant data meta-analysis. Risk of bias will be assessed (Cochrane risk of bias tool for randomised trials). Participant and trial characteristics, interventions and outcomes data of included studies will be summarised. Meta-analyses will entail a one-stage model, which will account for the heterogeneity across and the clustering between studies. Multiple imputation using chained equations will be used to account for the missing data. ETHICS AND DISSEMINATION This individual participant data meta-analysis does not require ethical review as anonymised participant data will be used and no new data collected. Additionally, eligible trials were granted approval by institutional review boards or research ethics committees and informed consent was provided for participants. Data sharing agreements are in place permitting contribution of data. The study findings will be disseminated at conferences and through peer-reviewed publications. PROSPERO REGISTRATION NUMBER CRD42019152526.
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Affiliation(s)
- Jennifer R A Jones
- Physiotherapy Department, The University of Melbourne, Parkville, Victoria, Australia
- Physiotherapy Department, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia
| | - Sue Berney
- Physiotherapy Department, The University of Melbourne, Parkville, Victoria, Australia
- Physiotherapy Department, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia
| | - Michael J Berry
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, North Carolina, USA
| | - D Clark Files
- Pulmonary, Critical Care, Allergy and Immunologic Disease, Wake Forest University, Winston-Salem, North Carolina, USA
- Wake Forest Critical Illness Injury and Recovery Research Center, Wake Forest University, Winston-Salem, North Carolina, USA
| | - David M Griffith
- Anaesthesia, Critical Care and Pain, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Luke A McDonald
- Physiotherapy Department, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia
| | - Peter E Morris
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Marc Moss
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Amy Nordon-Craft
- Physical Therapy Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Timothy Walsh
- Anaesthesia, Critical Care and Pain, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ian Gordon
- Statistical Consulting Centre, The University of Melbourne, Parkville, Victoria, Australia
| | - Amalia Karahalios
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Zudin Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
- Adult Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Linda Denehy
- Melbourne School of Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
- Allied Health, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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9
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Baldwin CE, Rowlands AV, Fraysse F, Johnston KN. The sedentary behaviour and physical activity patterns of survivors of a critical illness over their acute hospitalisation: An observational study. Aust Crit Care 2020; 33:272-280. [DOI: 10.1016/j.aucc.2019.10.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 10/24/2019] [Accepted: 10/26/2019] [Indexed: 11/26/2022] Open
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10
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Flower L, Puthucheary Z. Muscle wasting in the critically ill patient: how to minimise subsequent disability. Br J Hosp Med (Lond) 2020; 81:1-9. [PMID: 32339009 DOI: 10.12968/hmed.2020.0045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Muscle wasting in critically ill patients is the most common complication associated with critical care. It has significant effects on physical and psychological health, mortality and quality of life. It is most severe in the first few days of illness and in the most critically unwell patients, with muscle loss estimated to occur at 2-3% per day. This muscle loss is likely a result of a reduction in protein synthesis relative to muscle breakdown, resulting in altered protein homeostasis. The associated weakness is associated with in an increase in both short- and long-term mortality and morbidity, with these detrimental effects demonstrated up to 5 years post discharge. This article highlights the significant impact that muscle wasting has on critically ill patients' outcomes, how this can be reduced, and how this might change in the future.
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Affiliation(s)
- Luke Flower
- Department of Anaesthetics, University College Hospital, London, UK
| | - Zudin Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Adult Critical Care Unit, Royal London Hospital, London, UK
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11
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Effect of Intermittent or Continuous Feed on Muscle Wasting in Critical Illness: A Phase 2 Clinical Trial. Chest 2020; 158:183-194. [PMID: 32247714 DOI: 10.1016/j.chest.2020.03.045] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/09/2020] [Accepted: 03/15/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Acute skeletal muscle wasting in critical illness is associated with excess morbidity and mortality. Continuous feeding may suppress muscle protein synthesis as a result of the muscle-full effect, unlike intermittent feeding, which may ameliorate it. RESEARCH QUESTION Does intermittent enteral feed decrease muscle wasting compared with continuous feed in critically ill patients? STUDY DESIGN AND METHODS In a phase 2 interventional single-blinded randomized controlled trial, 121 mechanically ventilated adult patients with multiorgan failure were recruited following prospective informed consultee assent. They were randomized to the intervention group (intermittent enteral feeding from six 4-hourly feeds per 24 h, n = 62) or control group (standard continuous enteral feeding, n = 59). The primary outcome was 10-day loss of rectus femoris muscle cross-sectional area determined by ultrasound. Secondary outcomes included nutritional target achievements, plasma amino acid concentrations, glycemic control, and physical function milestones. RESULTS Muscle loss was similar between arms (-1.1% [95% CI, -6.1% to -4.0%]; P = .676). More intermittently fed patients received 80% or more of target protein (OR, 1.52 [1.16-1.99]; P < .001) and energy (OR, 1.59 [1.21-2.08]; P = .001). Plasma branched-chain amino acid concentrations before and after feeds were similar between arms on trial day 1 (71 μM [44-98 μM]; P = .547) and trial day 10 (239 μM [33-444 μM]; P = .178). During the 10-day intervention period the coefficient of variation for glucose concentrations was higher with intermittent feed (17.84 [18.6-20.4]) vs continuous feed (12.98 [14.0-15.7]; P < .001). However, days with reported hypoglycemia and insulin usage were similar in both groups. Safety profiles, gastric intolerance, physical function milestones, and discharge destinations did not differ between groups. INTERPRETATION Intermittent feeding in early critical illness is not shown to preserve muscle mass in this trial despite resulting in a greater achievement of nutritional targets than continuous feeding. However, it is feasible and safe. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02358512; URL: www.clinicaltrials.gov.
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Quality of Life and 1-Year Survival in Patients With Early Septic Shock: Long-Term Follow-Up of the Australasian Resuscitation in Sepsis Evaluation Trial. Crit Care Med 2020; 47:765-773. [PMID: 30985391 DOI: 10.1097/ccm.0000000000003762] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To examine long-term survival and quality of life of patients with early septic shock. DESIGN Prospective, randomized, parallel-group trial. SETTING Fifty-one hospitals in Australia, New Zealand, Finland, Hong Kong, and the Republic of Ireland. PATIENTS One-thousand five-hundred ninety-one patients who presented to the emergency department with early septic shock between October 2008 and April 2014, and were enrolled in the Australasian Resuscitation in Sepsis Evaluation trial. INTERVENTIONS Early goal-directed therapy versus usual care. MEASUREMENTS AND MAIN RESULTS Long-term survival was measured up to 12 months postrandomization. Health-related quality of life was measured using the EuroQoL-5D-3L, Short Form 36 and Assessment of Quality of Life 4D at baseline, and at 6 and 12 months following randomization. Mortality data were available for 1,548 patients (97.3%) and 1,515 patients (95.2%) at 6 and 12 months, respectively. Health-related quality of life data were available for 85.1% of survivors at 12 months. There were no significant differences in mortality between groups at either 6 months (early goal-directed therapy 21.8% vs usual care 22.6%; p = 0.70) or 12 months (early goal-directed therapy 26.4% vs usual care 27.9%; p = 0.50). There were no group differences in health-related quality of life at either 6 or 12 months (EuroQoL-5D-3L utility scores at 12 mo early goal-directed therapy 0.65 ± 0.33 vs usual care 0.64 ± 0.34; p = 0.50), with the health-related quality of life of both groups being significantly lower than population norms. CONCLUSIONS In patients presenting to the emergency department with early septic shock, early goal-directed therapy compared with usual care did not reduce mortality nor improve health-related quality of life at either 6 or 12 months.
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Determinants of Health-Related Quality of Life After ICU: Importance of Patient Demographics, Previous Comorbidity, and Severity of Illness. Crit Care Med 2019; 46:594-601. [PMID: 29293149 DOI: 10.1097/ccm.0000000000002952] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES ICU survivors frequently report reduced health-related quality of life, but the relative importance of preillness versus acute illness factors in survivor populations is not well understood. We aimed to explore health-related quality of life trajectories over 12 months following ICU discharge, patterns of improvement, or deterioration over this period, and the relative importance of demographics (age, gender, social deprivation), preexisting health (Functional Comorbidity Index), and acute illness severity (Acute Physiology and Chronic Health Evaluation II score, ventilation days) as determinants of health-related quality of life and relevant patient-reported symptoms during the year following ICU discharge. DESIGN Nested cohort study within a previously published randomized controlled trial. SETTING Two ICUs in Edinburgh, Scotland. PATIENTS Adult ICU survivors (n = 240) who required more than 48 hours of mechanical ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We prospectively collected data for age, gender, social deprivation (Scottish index of multiple deprivation), preexisting comorbidity (Functional Comorbidity Index), Acute Physiology and Chronic Health Evaluation II score, and days of mechanical ventilation. Health-related quality of life (Medical Outcomes Study Short Form version 2 Physical Component Score and Mental Component Score) and patient-reported symptoms (appetite, fatigue, pain, joint stiffness, and breathlessness) were measured at 3, 6, and 12 months. Mean Physical Component Score and Mental Component Score were reduced at all time points with minimal change between 3 and 12 months. In multivariable analysis, increasing pre-ICU comorbidity count was strongly associated with lower health-related quality of life (Physical Component Score β = -1.56 [-2.44 to -0.68]; p = 0.001; Mental Component Score β = -1.45 [-2.37 to -0.53]; p = 0.002) and more severe self-reported symptoms. In contrast, Acute Physiology and Chronic Health Evaluation II score and mechanical ventilation days were not associated with health-related quality of life. Older age (β = 0.33 [0.19-0.47]; p < 0.001) and lower social deprivation (β = 1.38 [0.03-2.74]; p = 0.045) were associated with better Mental Component Score health-related quality of life. CONCLUSIONS Preexisting comorbidity counts, but not severity of ICU illness, are strongly associated with health-related quality of life and physical symptoms in the year following critical illness.
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Bear DE, Griffith D, Puthucheary ZA. Emerging outcome measures for nutrition trials in the critically ill. Curr Opin Clin Nutr Metab Care 2018; 21:417-422. [PMID: 30148741 DOI: 10.1097/mco.0000000000000507] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Mortality has long been the gold-standard outcome measure for intensive care clinical trials. However, as the critical care community begins to understand and accept that survivorship is associated with functional disability and a health and socioeconomic burden, the clinical and research focus has begun to shift towards long-term physical function RECENT FINDINGS: To use mortality as a primary outcome measure, one would either have to choose an improbable effect (e.g. a difference of 5-10% in mortality as a result of a single intervention) or recruit a larger number of patients, the latter being unfeasible for most critical care trials.Outcome measures will need to match interventions. As an example, amino acids, or intermittent feeding, can stimulate muscle protein synthesis, and so prevention of muscle wasting may seem an appropriate outcome measure when assessing the effectiveness of these interventions. Testing the effectiveness of these interventions requires the development of novel outcome measures that are targeted and acceptable to patients. We describe advancements in dual-energy X-ray absorptiometry scanning, bio-impedence analysis, MRI and muscle ultrasound in this patient group that are beginning to address this development need. SUMMARY New approaches to outcome assessment are beginning to appear in post-ICU research, which promise to improve our understanding of nutrition and exercise interventions on skeletal muscle structure, composition and function, without causing undue suffering to the patient.
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Affiliation(s)
- Danielle E Bear
- Department of Nutrition and Dietetics
- Department of Critical Care
- Lane Fox Clinical Respiratory Research Unit, Guy's and St Thomas' NHS Foundation Trust
- Centre for Human and Applied Physiological Sciences, King's College London
| | - David Griffith
- Anaesthesia, Critical Care and Pain Medicine, The University of Edinburgh, Edinburgh
| | - Zudin A Puthucheary
- Centre for Human and Applied Physiological Sciences, King's College London
- Centre for Human Health and Performance, Department of Medicine, University College London
- Adult Intensive Care Unit, Royal Free Hospital NHS Foundation Trust London, London, UK
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Skeletal Muscle Weakness Is Associated With Both Early and Late Mortality After Acute Respiratory Distress Syndrome. Crit Care Med 2018; 45:563-565. [PMID: 28212226 DOI: 10.1097/ccm.0000000000002243] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Puthucheary ZA, Astin R, Mcphail MJW, Saeed S, Pasha Y, Bear DE, Constantin D, Velloso C, Manning S, Calvert L, Singer M, Batterham RL, Gomez-Romero M, Holmes E, Steiner MC, Atherton PJ, Greenhaff P, Edwards LM, Smith K, Harridge SD, Hart N, Montgomery HE. Metabolic phenotype of skeletal muscle in early critical illness. Thorax 2018; 73:926-935. [PMID: 29980655 DOI: 10.1136/thoraxjnl-2017-211073] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 05/17/2018] [Accepted: 05/28/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To characterise the sketetal muscle metabolic phenotype during early critical illness. METHODS Vastus lateralis muscle biopsies and serum samples (days 1 and 7) were obtained from 63 intensive care patients (59% male, 54.7±18.0 years, Acute Physiology and Chronic Health Evaluation II score 23.5±6.5). MEASUREMENTS AND MAIN RESULTS From day 1 to 7, there was a reduction in mitochondrial beta-oxidation enzyme concentrations, mitochondrial biogenesis markers (PGC1α messenger mRNA expression (-27.4CN (95% CI -123.9 to 14.3); n=23; p=0.025) and mitochondrial DNA copy number (-1859CN (IQR -5557-1325); n=35; p=0.032). Intramuscular ATP content was reduced compared tocompared with controls on day 1 (17.7mmol/kg /dry weight (dw) (95% CI 15.3 to 20.0) vs. 21.7 mmol/kg /dw (95% CI 20.4 to 22.9); p<0.001) and decreased over 7 days (-4.8 mmol/kg dw (IQR -8.0-1.2); n=33; p=0.001). In addition, the ratio of phosphorylated:total AMP-K (the bioenergetic sensor) increased (0.52 (IQR -0.09-2.6); n=31; p<0.001). There was an increase in intramuscular phosphocholine (847.2AU (IQR 232.5-1672); n=15; p=0.022), intramuscular tumour necrosis factor receptor 1 (0.66 µg (IQR -0.44-3.33); n=29; p=0.041) and IL-10 (13.6 ng (IQR 3.4-39.0); n=29; p=0.004). Serum adiponectin (10.3 µg (95% CI 6.8 to 13.7); p<0.001) and ghrelin (16.0 ng/mL (IQR -7-100); p=0.028) increased. Network analysis revealed a close and direct relationship between bioenergetic impairment and reduction in muscle mass and between intramuscular inflammation and impaired anabolic signaling. ATP content and muscle mass were unrelated to lipids delivered. CONCLUSIONS Decreased mitochondrial biogenesis and dysregulated lipid oxidation contribute to compromised skeletal muscle bioenergetic status. In addition, intramuscular inflammation was associated with impaired anabolic recovery with lipid delivery observed as bioenergetically inert. Future clinical work will focus on these key areas to ameliorate acute skeletal muscle wasting. TRIAL REGISTRATION NUMBER NCT01106300.
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Affiliation(s)
- Zudin A Puthucheary
- Institute for Sport, Exercise and Health, University College London, London, UK
- Department of Medicine, Centre for Human Health and Performance, University College London, London, UK
- Intensive Care Unit, Royal Free London NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Ronan Astin
- Institute for Sport, Exercise and Health, University College London, London, UK
- Department of Medicine, Centre for Human Health and Performance, University College London, London, UK
| | - Mark J W Mcphail
- Hepatology and Gastroenterology, St Mary's Hospital, Imperial College London, London, UK
- Institute of Liver Studies, Kings College Hospital NHS Foundation Trust, London, UK
| | - Saima Saeed
- Wolfson Institute Centre for Intensive Care Medicine, University College London, London, UK
| | - Yasmin Pasha
- Hepatology and Gastroenterology, St Mary's Hospital, Imperial College London, London, UK
| | - Danielle E Bear
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's and St Thomas' Foundation Trust, London, London, UK
| | - Despina Constantin
- Medical Research Council/Arthritis Research UK Centre for Musculoskeletal Aging Research, National Institute for Health Research Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Cristiana Velloso
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Sean Manning
- Centre for Obesity Research, University College London, London, UK
- National Institute of Health Research, UCLH Biomedical Research Centre, University College London Hospitals, London
- School of Medicine, University College Cork, Cork, Ireland
| | - Lori Calvert
- Northwest Anglia foundation Trust, Peterborough City Hospital NHS Trust, Peterborough, UK
| | - Mervyn Singer
- Intensive Care Unit, Royal Free London NHS Foundation Trust, London, UK
- Wolfson Institute Centre for Intensive Care Medicine, University College London, London, UK
| | - Rachel L Batterham
- Centre for Obesity Research, University College London, London, UK
- National Institute of Health Research, UCLH Biomedical Research Centre, University College London Hospitals, London
| | - Maria Gomez-Romero
- Biomolecular Medicine, Division of Computational and Systems Medicine, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, London, UK
| | - Elaine Holmes
- Biomolecular Medicine, Division of Computational and Systems Medicine, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, London, UK
| | - Michael C Steiner
- Institute for Lung Health, Leicester NIHR Biomedical Research Centre-Respiratory, University of Leicester, Leicester, UK
| | - Philip J Atherton
- Medical Research Council/Arthritis Research UK Centre for Musculoskeletal Aging Research, National Institute for Health Research Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Paul Greenhaff
- Medical Research Council/Arthritis Research UK Centre for Musculoskeletal Aging Research, National Institute for Health Research Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Lindsay M Edwards
- Digital, Data & Analytics Unit, Respiratory Therapy Area, GlaxoSmithKline Medicines Research Centre, Stevenage, UK
| | - Kenneth Smith
- Medical Research Council/Arthritis Research UK Centre for Musculoskeletal Aging Research, National Institute for Health Research Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Stephen D Harridge
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Nicholas Hart
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's and St Thomas' Foundation Trust, London, London, UK
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' Foundation Trust, London, UK
| | - Hugh E Montgomery
- Institute for Sport, Exercise and Health, University College London, London, UK
- Department of Medicine, Centre for Human Health and Performance, University College London, London, UK
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Paton M, Lane R, Hodgson CL. Early Mobilization in the Intensive Care Unit to Improve Long-Term Recovery. Crit Care Clin 2018; 34:557-571. [DOI: 10.1016/j.ccc.2018.06.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Berney SC, Rose JW, Denehy L, Granger CL, Ntoumenopoulos G, Crothers E, Steel B, Clarke S, Skinner EH. Commencing Out-of-Bed Rehabilitation in Critical Care-What Influences Clinical Decision-Making? Arch Phys Med Rehabil 2018; 100:261-269.e2. [PMID: 30172644 DOI: 10.1016/j.apmr.2018.07.438] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/23/2018] [Accepted: 07/25/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To develop a decision tree that objectively identifies the most discriminative variables in the decision to provide out-of-bed rehabilitation, measure the effect of this decision and to identify the factors that intensive care unit (ICU) practitioners think most influential in that clinical decision. DESIGN A prospective 3-part study: (1) consensus identification of influential factors in mobilization via survey; (2) development of an early rehabilitation decision tree; (3) measurement of practitioner mobilization decision-making. Treating practitioners of patients expected to stay >96 hours were asked if they would provide out-of-bed rehabilitation and rank factors that influenced this decision from an a priori defined list developed from a literature review and expert consultation. SETTING Four tertiary metropolitan ICUs. PARTICIPANTS Practitioners (ICU medical, nursing, and physiotherapy staff) (N=507). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES A decision tree was constructed using binary recursive partitioning to determine the factor that best classified patients suitable for out-of-bed rehabilitation. Descriptive statistics were used to describe practitioner and patient samples as well as patient adverse events associated with out-of-bed rehabilitation and the factors prioritized by ICU practitioners. RESULTS There were 1520 practitioner decisions representing 472 individual patient decisions. Practitioners classified patients suitable for out-of-bed rehabilitation on 149 occasions and not suitable on 323 occasions. Decision tree analysis showed the presence of an endotracheal tube (ETT) and sedation state were the only discriminative variables that predicted patient suitability for rehabilitation. In contrast, medical staff and nurses reported that ventilator status was the most influential factor in their decision not to provide rehabilitation while physiotherapists ranked sedation most highly. The presence of muscle weakness did not inform the decision to provide rehabilitation. CONCLUSION These results confirm previous observational reports that the presence of an ETT remains a major obstacle to the provision of rehabilitation for critically ill patients. Despite rehabilitation being effective for improving muscle strength, the presence of muscle weakness did not influence the decision to provide rehabilitation.
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Affiliation(s)
- Sue C Berney
- Physiotherapy Department, Austin Health, Melbourne, Australia; Physiotherapy Department, The University of Melbourne, Melbourne, Australia; Institute for Breathing and Sleep, Melbourne, Australia.
| | - Joleen W Rose
- Physiotherapy Department, Austin Health, Melbourne, Australia
| | - Linda Denehy
- Physiotherapy Department, The University of Melbourne, Melbourne, Australia
| | - Catherine L Granger
- Physiotherapy Department, The University of Melbourne, Melbourne, Australia; Allied Health Department, Melbourne Health, Melbourne, Australia
| | | | - Elise Crothers
- Physiotherapy Department, St Vincent's Hospital, Darlinghurst, Australia
| | | | - Sandy Clarke
- Statistical Consulting Centre, School of Mathematics and Statistics, The University of Melbourne, Melbourne, Australia
| | - Elizabeth H Skinner
- Institute for Breathing and Sleep, Melbourne, Australia; Western Health, Melbourne, Australia; Monash University, Melbourne, Australia
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Battle C, James K, Temblett P, Hutchings H. Supervised exercise rehabilitation in survivors of critical illness: A randomised controlled trial. J Intensive Care Soc 2018; 20:18-26. [PMID: 30792758 DOI: 10.1177/1751143718767061] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objectives To investigate the impact of a six-week supervised exercise programme on cardiopulmonary fitness, balance, muscle strength and anxiety and depression in patients who have been discharged home from hospital following an intensive care unit length of stay of greater than 48 h. To investigate patients' perceptions of a six-week supervised exercise programme delivered at three months post hospital discharge. Design A single centre parallel, randomised controlled trial. Setting Outpatient department of a university teaching hospital in the UK. Participants Sixty adult survivors of critical illness, at three months post-hospital discharge. Intervention A six-week individually prescribed and supervised exercise program, with associated advice to home exercise modification. Twice weekly exercise sessions were individualised to participant's functional status and included cardiopulmonary, balance and strengthening exercises. Follow up at seven weeks, six months and 12 months. Outcome measures Six-Minute Walk Test, BERG balance test, grip strength and Hospital Anxiety and Depression Scale. A pre-designed survey was used to explore patient perceptions of the programme. Results Sixty participants (n = 30 received allocated programme in both control and treatment groups) were randomised. Loss to follow up resulted in n = 34 participants for intention to treat analysis at 12 months follow up (leaving n = 19 in control group, n = 15 in treatment group). Median participant age at enrolment was 62 years (interquartile range: 49-72), with a median intensive care unit length of stay of nine days (interquartile range: 4-17). No significant differences were found for the Six-Minute Walk Test at any time point (p > 0.05). Anxiety levels and balance were significantly improved in the treatment group at 12 months (p = 0.006 and p = 0.040, respectively). Conclusions Further research is needed into appropriate interventions and outcome measures, target patient populations and timing of such intervention post-hospital discharge.
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Affiliation(s)
- Ceri Battle
- Ed Major Critical Care Unit, Morriston Hospital, Swansea, UK.,Swansea University Medical School, Swansea University, Swansea, UK
| | - Karen James
- Ed Major Critical Care Unit, Morriston Hospital, Swansea, UK
| | - Paul Temblett
- Ed Major Critical Care Unit, Morriston Hospital, Swansea, UK
| | - Hayley Hutchings
- Swansea University Medical School, Swansea University, Swansea, UK
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Haines KJ, Berney S, Warrillow S, Denehy L. Long-term recovery following critical illness in an Australian cohort. J Intensive Care 2018; 6:8. [PMID: 29445502 PMCID: PMC5800039 DOI: 10.1186/s40560-018-0276-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 01/22/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Almost all data on 5-year outcomes for critical care survivors come from North America and Europe. The aim of this study was to investigate long-term mortality, physical function, psychological outcomes and health-related quality of life in a mixed intensive care unit cohort in Australia. METHODS This longitudinal study evaluated 4- to 5-year outcomes. Physical function (six-minute walk test) and health-related quality of life (Short Form 36 Version 2) were compared to 1-year outcomes and population norms. New psychological data (Center for Epidemiological Studies-Depression, Impact of Events Scale) was collected at follow-up. RESULTS Of the 150 participants, 66 (44%) patients were deceased by follow-up. Fifty-six survivors were included with a mean (SD) age of 64 (14.2). Survivors' mean (SD) six-minute walk distance increased between 1 and 4 to 5 years (465.8 m (148.9) vs. 507.5 m (118.2)) (mean difference = - 24.5 m, CI - 58.3, 9.2, p = 0.15). Depressive symptoms were low: median (IQR) score of 7.0 (1.0-15.0). The mean level of post-traumatic stress symptoms was low-median (IQR) score of 1.0 (0-11.0)-with only 9 (16%) above the threshold for potentially disordered symptoms. Short-Form 36 Physical and Mental Component Scores did not change between 1 and 4 to 5 years (46.4 (7.9) vs. 46.7 (8.1) and 48.8 (13) vs. 48.8 (11.1)) and were within a standard deviation of normal. CONCLUSIONS Outcomes of critical illness are not uniform across nations. Mortality was increased in this cohort; however, survivors achieved a high level of recovery for physical function and health-related quality of life with low psychological morbidity at follow-up. TRIAL REGISTRATION The trial was registered with the Australian New Zealand Clinical Trials Registry ACTRN12605000776606.
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Affiliation(s)
- Kimberley J. Haines
- Physiotherapy Department, Western Health, Furlong Road, St. Albans, VIC 3021 Australia
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, 200 Berkeley Street, Parkville, VIC 3010 Australia
| | - Sue Berney
- Department of Physiotherapy, Austin Hospital, 145 Studley Road, Heidelberg, VIC 3084 Australia
| | - Stephen Warrillow
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, VIC 3084 Australia
| | - Linda Denehy
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, 200 Berkeley Street, Parkville, VIC 3010 Australia
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Denehy L, Granger CL, El-Ansary D, Parry SM. Advances in cardiorespiratory physiotherapy and their clinical impact. Expert Rev Respir Med 2018; 12:203-215. [PMID: 29376440 DOI: 10.1080/17476348.2018.1433034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Cardiorespiratory physiotherapy is an evidence-based practice that has evolved alongside changes in medical and surgical management, analgesia, the ageing society and increasing comorbidities of our patient populations. Continued research provides the profession with the ability to adapt to meet the changing patient and community needs. Areas covered: This review focuses on surgical, respiratory and critical care settings discussing the most significant changes over the past decade with an increased focus on rehabilitation across the care continuum and a shift away from providing predominately airway clearance in established disease populations but also providing this in emerging groups. Further important changes are identification and emphases on patient self-management including changing their behaviour to more positively embrace wellness, particularly increasing physical activity levels. This paper outlines these changes and offers speculation on factors that may impact the profession in the future. Expert commentary: The increasing focus on new technologies, physical activity levels, changes to the health systems in different countries and an increasingly comorbid and ageing society will shape the next steps in the evolution of cardiorespiratory physiotherapy. Continued research is vital to keep pace with these changes so that physiotherapists can provide the most effective treatments to improve patient outcomes.
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Affiliation(s)
- Linda Denehy
- a Department of Physiotherapy, Melbourne School of Health Sciences , The University of Melbourne , Melbourne , Victoria , Australia
| | - Catherine L Granger
- a Department of Physiotherapy, Melbourne School of Health Sciences , The University of Melbourne , Melbourne , Victoria , Australia
| | - Doa El-Ansary
- b Department of Cardiothoracic Surgery , Royal Melbourne Hospital, Royal Parade , Parkville , Australia
| | - Selina M Parry
- a Department of Physiotherapy, Melbourne School of Health Sciences , The University of Melbourne , Melbourne , Victoria , Australia
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Brown SM, Wilson EL, Presson AP, Dinglas VD, Greene T, Hopkins RO, Needham DM. Understanding patient outcomes after acute respiratory distress syndrome: identifying subtypes of physical, cognitive and mental health outcomes. Thorax 2017; 72:1094-1103. [PMID: 28778920 PMCID: PMC5690818 DOI: 10.1136/thoraxjnl-2017-210337] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/23/2017] [Accepted: 07/10/2017] [Indexed: 11/04/2022]
Abstract
PURPOSE With improving short-term mortality in acute respiratory distress syndrome (ARDS), understanding survivors' posthospitalisation outcomes is increasingly important. However, little is known regarding associations among physical, cognitive and mental health outcomes. Identification of outcome subtypes may advance understanding of post-ARDS morbidities. METHODS We analysed baseline variables and 6-month health status for participants in the ARDS Network Long-Term Outcomes Study. After division into derivation and validation datasets, we used weighted network analysis to identify subtypes from predictors and outcomes in the derivation dataset. We then used recursive partitioning to develop a subtype classification rule and assessed adequacy of the classification rule using a kappa statistic with the validation dataset. RESULTS Among 645 ARDS survivors, 430 were in the derivation and 215 in the validation datasets. Physical and mental health status, but not cognitive status, were closely associated. Four distinct subtypes were apparent (percentages in the derivation cohort): (1) mildly impaired physical and mental health (22% of patients), (2) moderately impaired physical and mental health (39%), (3) severely impaired physical health with moderately impaired mental health (15%) and (4) severely impaired physical and mental health (24%). The classification rule had high agreement (kappa=0.89 in validation dataset). Female Latino smokers had the poorest status, while male, non-Latino non-smokers had the best status. CONCLUSIONS We identified four post-ARDS outcome subtypes that were predicted by sex, ethnicity, pre-ARDS smoking status and other baseline factors. These subtypes may help develop tailored rehabilitation strategies, including investigation of combined physical and mental health interventions, and distinct interventions to improve cognitive outcomes.
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Affiliation(s)
- Samuel M. Brown
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, USA
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, USA
- Pulmonary and Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Emily L. Wilson
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, USA
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, USA
| | - Angela P. Presson
- Study Design and Biostatistics Center and Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Victor D. Dinglas
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tom Greene
- Study Design and Biostatistics Center and Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ramona O. Hopkins
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, USA
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, USA
- Department of Psychology and Neuroscience Center, Brigham Young University, Provo, Utah, USA
| | - Dale M. Needham
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Connolly B, Denehy L. Hindsight and moving the needle forwards on rehabilitation trial design. Thorax 2017; 73:203-205. [DOI: 10.1136/thoraxjnl-2017-210588] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Muscle mass and physical recovery in ICU: innovations for targeting of nutrition and exercise. Curr Opin Crit Care 2017; 23:269-278. [PMID: 28661414 DOI: 10.1097/mcc.0000000000000431] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW We have significantly improved hospital mortality from sepsis and critical illness in last 10 years; however, over this same period we have tripled the number of 'ICU survivors' going to rehabilitation. Furthermore, as up to half the deaths in the first year following ICU admission occur post-ICU discharge, it is unclear how many of these patients ever returned home or a meaningful quality of life. For those who do survive, recent data reveals many 'ICU survivors' will suffer significant functional impairment or post-ICU syndrome (PICS). Thus, new innovative metabolic and exercise interventions to address PICS are urgently needed. These should focus on optimal nutrition and lean body mass (LBM) assessment, targeted nutrition delivery, anabolic/anticatabolic strategies, and utilization of personalized exercise intervention techniques, such as utilized by elite athletes to optimize preparation and recovery from critical care. RECENT FINDINGS New data for novel LBM analysis technique such as computerized tomography scan and ultrasound analysis of LBM are available showing objective measures of LBM now becoming more practical for predicting metabolic reserve and effectiveness of nutrition/exercise interventions. 13C-Breath testing is a novel technique under study to predict infection earlier and predict over-feeding and under-feeding to target nutrition delivery. New technologies utilized routinely by athletes such as muscle glycogen ultrasound also show promise. Finally, the role of personalized cardiopulmonary exercise testing to target preoperative exercise optimization and post-ICU recovery are becoming reality. SUMMARY New innovative techniques are demonstrating promise to target recovery from PICS utilizing a combination of objective LBM and metabolic assessment, targeted nutrition interventions, personalized exercise interventions for prehabilitation and post-ICU recovery. These interventions should provide hope that we will soon begin to create more 'survivors' and fewer victim's post-ICU care.
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Neumeier A, Nordon-Craft A, Malone D, Schenkman M, Clark B, Moss M. Prolonged acute care and post-acute care admission and recovery of physical function in survivors of acute respiratory failure: a secondary analysis of a randomized controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:190. [PMID: 28732512 PMCID: PMC5521116 DOI: 10.1186/s13054-017-1791-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 07/07/2017] [Indexed: 11/25/2022]
Abstract
Background The proportion of survivors of acute respiratory failure is growing; yet, many do not regain full function and require prolonged admission in an acute or post-acute care facility. Little is known about their trajectory of functional recovery. We sought to determine whether prolonged admission influenced the trajectory of physical function recovery and whether patient age modified the recuperation rate. Methods We performed a secondary analysis of a randomized clinical trial of intensive physical therapy for patients with acute respiratory failure requiring mechanical ventilation for ≥4 days. The primary outcome was Continuous Scale Physical Functional Performance, short form (CS-PFP-10), score. Predictor variables included prolonged admission in an acute or post-acute care facility at 1 month, time, and patient age. To determine whether the association between admission and functional outcome varied over time, a multivariable mixed effects linear regression model was fit using an interaction between prolonged admission and time with a primary outcome of total CS-PFP-10 score. Results Of the 89 patients included, 56% (50 of 89) required prolonged admission. At 1 month, patients who remained admitted had CS-PFP-10 scores that were 20.1 (CI 10.4–29.8) points lower (p < 0.0001) than patients who were discharged to home. However, there was no difference in the rate at which physical function improved from 3 to 6 months for patients who required prolonged admission compared with those who returned home (p = 0.24 for interaction between prolonged admission and time). Adjusted for age, Acute Physiology and Chronic Health Evaluation II score, and sex, both groups had CS-PFP-10 scores that were 8.2 (CI 4.5–12.0) points higher at 6 months than at 3 months (p < 0.0001). For each additional year in patient age, CS-PFP-10 recovered 0.36 points slower (95% CI 0.12–0.61; p = 0.004). Conclusions Patients who require prolonged admission after acute respiratory failure have significantly lower physical functional performance than patients who return home. However, the rates of physical functional recovery between the two groups do not differ. The majority of survivors do not recover sufficiently to achieve functional independence by 6 months. Older age negatively influences the trajectory of functional recovery. Trial registration ClinicalTrials.gov, NCT01058421. Registered on 26 January 2010. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1791-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna Neumeier
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Research 2, Box C272, 12700 East 19th Avenue, Aurora, CO, 80045, USA.
| | - Amy Nordon-Craft
- Physical Therapy Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Dan Malone
- Physical Therapy Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Margaret Schenkman
- Physical Therapy Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Brendan Clark
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Research 2, Box C272, 12700 East 19th Avenue, Aurora, CO, 80045, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Research 2, Box C272, 12700 East 19th Avenue, Aurora, CO, 80045, USA
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An Exploratory Study of Long-Term Outcome Measures in Critical Illness Survivors: Construct Validity of Physical Activity, Frailty, and Health-Related Quality of Life Measures. Crit Care Med 2017; 44:e362-9. [PMID: 26974547 DOI: 10.1097/ccm.0000000000001645] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Functional capacity is commonly impaired after critical illness. We sought to clarify the relationship between objective measures of physical activity, self-reported measures of health-related quality of life, and clinician reported global functioning capacity (frailty) in such patients, as well as the impact of prior chronic disease status on these functional outcomes. DESIGN Prospective outcome study of critical illness survivors. SETTING Community-based follow-up. PATIENTS Participants of the Musculoskeletal Ultrasound Study in Critical Care: Longitudinal Evaluation Study (NCT01106300), invasively ventilated for more than 48 hours and on the ICU greater than 7 days. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Physical activity levels (health-related quality of life [36-item short-form health survey] and daily step counts [accelerometry]) were compared to norm-based or healthy control scores, respectively. Controls for frailty (Clinical Frailty Score) were non-morbid, age- and gender-matched to survivors. Ninety-one patients were recruited on ICU admission: 41 were contacted for post-discharge assessment, and data were collected from 30 (14 female; mean age, 55.3 yr [95% CI, 48.3-62.3]; mean post-discharge, 576 d [95% CI, 539-614]). Patients' mean daily step count (5,803; 95% CI, 4,792-6,813) was lower than that in controls (11,735; 95% CI, 10,928-12,542; p < 0.001), and lower in those with preexisting chronic disease than without (2,989 [95% CI, 776-5,201] vs 7,737 [95% CI, 4,907-10,567]; p = 0.013). Physical activity measures (accelerometry, health-related quality of life, and frailty) demonstrated good construct validity across all three tools. Step variability (from SD) was highly correlated with daily steps (r = 0.67; p < 0.01) demonstrating a potential boundary constraint. CONCLUSIONS Subjective and objective measures of physical activity are all informative in ICU survivors. They are all reduced 18 months post-discharge in ICU survivors, and worse in those with pre-admission chronic disease states. Investigating interventions to improve functional capacity in ICU survivors will require stratification based on the presence of premorbidity.
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The impact of disability in survivors of critical illness. Intensive Care Med 2017; 43:992-1001. [PMID: 28534110 DOI: 10.1007/s00134-017-4830-0] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 05/02/2017] [Indexed: 01/30/2023]
Abstract
PURPOSE To use the World Health Organisation's International Classification of Functioning to measure disability following critical illness using patient-reported outcomes. METHODS A prospective, multicentre cohort study conducted in five metropolitan intensive care units (ICU). Participants were adults who had been admitted to the ICU, received more than 24 h of mechanical ventilation and survived to hospital discharge. The primary outcome was measurement of disability using the World Health Organisation's Disability Assessment Schedule 2.0. The secondary outcomes included the limitation of activities and changes to health-related quality of life comparing survivors with and without disability at 6 months after ICU. RESULTS We followed 262 patients to 6 months, with a mean age of 59 ± 16 years, and of whom 175 (67%) were men. Moderate or severe disability was reported in 65 of 262 (25%). Predictors of disability included a history of anxiety/depression [odds ratio (OR) 1.65 (95% confidence interval (CI) 1.22, 2.23), P = 0.001]; being separated or divorced [OR 2.87 (CI 1.35, 6.08), P = 0.006]; increased duration of mechanical ventilation [OR 1.04 (CI 1.01, 1.08), P = 0.03 per day]; and not being discharged to home from the acute hospital [OR 1.96 (CI 1.01, 3.70) P = 0.04]. Moderate or severe disability at 6 months was associated with limitation in activities, e.g. not returning to work or studies due to health (P < 0.002), and reduced health-related quality of life (P < 0.001). CONCLUSION Disability measured using patient-reported outcomes was prevalent at 6 months after critical illness in survivors and was associated with reduced health-related quality of life. Predictors of moderate or severe disability included a prior history of anxiety or depression, separation or divorce and a longer duration of mechanical ventilation. TRIAL REGISTRATION NCT02225938.
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Moss M, Nordon-Craft A, Malone D, Van Pelt D, Frankel SK, Warner ML, Kriekels W, McNulty M, Fairclough DL, Schenkman M. A Randomized Trial of an Intensive Physical Therapy Program for Patients with Acute Respiratory Failure. Am J Respir Crit Care Med 2017; 193:1101-10. [PMID: 26651376 DOI: 10.1164/rccm.201505-1039oc] [Citation(s) in RCA: 221] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
RATIONALE Early physical therapy (PT) interventions may benefit patients with acute respiratory failure by preventing or attenuating neuromuscular weakness. However, the optimal dosage of these interventions is currently unknown. OBJECTIVES To determine whether an intensive PT program significantly improves long-term physical functional performance compared with a standard-of-care PT program. METHODS Patients who required mechanical ventilation for at least 4 days were eligible. Enrolled patients were randomized to receive PT for up to 4 weeks delivered in an intensive or standard-of-care manner. Physical functional performance was assessed at 1, 3, and 6 months in survivors who were not currently in an acute or long-term care facility. The primary outcome was the Continuous Scale Physical Functional Performance Test short form (CS-PFP-10) score at 1 month. MEASUREMENTS AND MAIN RESULTS A total of 120 patients were enrolled from five hospitals. Patients in the intensive PT group received 12.4 ± 6.5 sessions for a total of 408 ± 261 minutes compared with only 6.1 ± 3.8 sessions for 86 ± 63 minutes in the standard-of-care group (P < 0.001 for both analyses). Physical function assessments were available for 86% of patients at 1 month, for 76% at 3 months, and for 60% at 6 months. In both groups, physical function was reduced yet significantly improved over time between 1, 3, and 6 months. When we compared the two interventions, we found no differences in the total CS-PFP-10 scores at all three time points (P = 0.73, 0.29, and 0.43, respectively) or in the total CS-PFP-10 score trajectory (P = 0.71). CONCLUSIONS An intensive PT program did not improve long-term physical functional performance compared with a standard-of-care program. Clinical trial registered with www.clinicaltrials.gov (NCT01058421).
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Affiliation(s)
- Marc Moss
- 1 Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine
| | | | | | | | - Stephen K Frankel
- 4 Division of Pulmonary Medicine, National Jewish Health, Denver, Colorado
| | - Mary Laird Warner
- 4 Division of Pulmonary Medicine, National Jewish Health, Denver, Colorado
| | | | - Monica McNulty
- 5 Colorado Health Outcomes Group, University of Colorado School of Medicine, Aurora, Colorado
| | - Diane L Fairclough
- 5 Colorado Health Outcomes Group, University of Colorado School of Medicine, Aurora, Colorado
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Brown SM, Wilson E, Presson AP, Zhang C, Dinglas VD, Greene T, Hopkins RO, Needham DM. Predictors of 6-month health utility outcomes in survivors of acute respiratory distress syndrome. Thorax 2017; 72:311-317. [PMID: 27440140 PMCID: PMC5518323 DOI: 10.1136/thoraxjnl-2016-208560] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 06/03/2016] [Accepted: 06/18/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND With improving short-term mortality in acute respiratory distress syndrome (ARDS), understanding and improving quality of life (QOL) outcomes in ARDS survivors is a clinical and research priority. We sought to identify variables associated with QOL, as measured by the EQ-5D health utility score, after ARDS using contemporary data science methods. METHODS Analysis of prospectively acquired baseline variables and 6-month EQ-5D health utility scores for adults with ARDS enrolled in the ARDS Network Long-Term Outcomes Study (ALTOS). Penalised regression identified predictors of health utility, with results validated using 10-fold cross-validation. RESULTS Among 616 ARDS survivors, several predictors were associated with 6-month EQ-5D utility scores, including two lifestyle factors. Specifically, older age, female sex, Hispanic/Latino ethnicity, current smoking and higher body mass index were associated with lower EQ-5D utilities, while living at home without assistance at baseline and AIDS were associated with higher EQ-5D utilities in ARDS survivors. No acute illness variables were associated with EQ-5D utility. CONCLUSIONS Acute illness variables do not appear to be associated with postdischarge QOL among ARDS survivors. Functional independence and lifestyle factors, such as obesity and tobacco smoking, were associated with worse QOL. Future analyses of postdischarge health utility among ARDS survivors should incorporate measures of demographics and functional independence at baseline. TRIAL REGISTRATION NUMBERS NCT00719446 (ALTOS), NCT00434993 (ALTA), NCT00609180 (EDEN/OMEGA), and NCT00883948 (EDEN); Post-results.
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Affiliation(s)
- Samuel M. Brown
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, UT
- Pulmonary and Critical Care, University of Utah School of Medicine, Salt Lake City, UT
| | - Emily Wilson
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, UT
| | - Angela P. Presson
- Study Design and Biostatistics Center and Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Chong Zhang
- Study Design and Biostatistics Center and Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Victor D. Dinglas
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Tom Greene
- Study Design and Biostatistics Center and Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Ramona O. Hopkins
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, UT
- Department of Psychology and Neuroscience Center, Brigham Young University, Provo, UT
| | - Dale M. Needham
- Outcomes After Critical Illness and Surgery 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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The ICM research agenda on intensive care unit-acquired weakness. Intensive Care Med 2017; 43:1270-1281. [DOI: 10.1007/s00134-017-4757-5] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 03/02/2017] [Indexed: 12/23/2022]
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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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Tipping CJ, Harrold M, Holland A, Romero L, Nisbet T, Hodgson CL. The effects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review. Intensive Care Med 2016; 43:171-183. [PMID: 27864615 DOI: 10.1007/s00134-016-4612-0] [Citation(s) in RCA: 360] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 10/25/2016] [Indexed: 12/27/2022]
Abstract
PURPOSE Early active mobilisation and rehabilitation in the intensive care unit (ICU) is being used to prevent the long-term functional consequences of critical illness. This review aimed to determine the effect of active mobilisation and rehabilitation in the ICU on mortality, function, mobility, muscle strength, quality of life, days alive and out of hospital to 180 days, ICU and hospital lengths of stay, duration of mechanical ventilation and discharge destination, linking outcomes with the World Health Organization International Classification of Function Framework. METHODS A PRISMA checklist-guided systematic review and meta-analysis of randomised and controlled clinical trials. RESULTS Fourteen studies of varying quality including a total of 1753 patients were reviewed. Active mobilisation and rehabilitation had no impact on short- or long-term mortality (p > 0.05). Meta-analysis showed that active mobilisation and rehabilitation led to greater muscle strength (body function) at ICU discharge as measured using the Medical Research Council Sum Score (mean difference 8.62 points, 95% confidence interval (CI) 1.39-15.86), greater probability of walking without assistance (activity limitation) at hospital discharge (odds ratio 2.13, 95% CI 1.19-3.83), and more days alive and out of hospital to day 180 (participation restriction) (mean difference 9.69, 95% CI 1.7-17.66). There were no consistent effects on function, quality of life, ICU or hospital length of stay, duration of mechanical ventilation or discharge destination. CONCLUSION Active mobilisation and rehabilitation in the ICU has no impact on short- and long-term mortality, but may improve mobility status, muscle strength and days alive and out of hospital to 180 days. REGISTRATION OF PROTOCOL NUMBER CRD42015029836.
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Affiliation(s)
- Claire J Tipping
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Physiotherapy, The Alfred Hospital, Melbourne, VIC, Australia
| | - Meg Harrold
- Curtin University, Perth, WA, Australia.,Royal Perth Hospital, Perth, WA, Australia
| | - Anne Holland
- Department of Physiotherapy, The Alfred Hospital, Melbourne, VIC, Australia.,Latrobe University, Melbourne, VIC, Australia
| | | | - Travis Nisbet
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia. .,Department of Physiotherapy, The Alfred Hospital, Melbourne, VIC, Australia.
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Major ME, Kwakman R, Kho ME, Connolly B, McWilliams D, Denehy L, Hanekom S, Patman S, Gosselink R, Jones C, Nollet F, Needham DM, Engelbert RHH, van der Schaaf M. Surviving critical illness: what is next? An expert consensus statement on physical rehabilitation after hospital discharge. Crit Care 2016; 20:354. [PMID: 27793165 PMCID: PMC5086052 DOI: 10.1186/s13054-016-1508-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 09/26/2016] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The study objective was to obtain consensus on physical therapy (PT) in the rehabilitation of critical illness survivors after hospital discharge. Research questions were: what are PT goals, what are recommended measurement tools, and what constitutes an optimal PT intervention for survivors of critical illness? METHODS A Delphi consensus study was conducted. Panelists were included based on relevant fields of expertise, years of clinical experience, and publication record. A literature review determined five themes, forming the basis for Delphi round one, which was aimed at generating ideas. Statements were drafted and ranked on a 5-point Likert scale in two additional rounds with the objective to reach consensus. Results were expressed as median and semi-interquartile range, with the consensus threshold set at ≤0.5. RESULTS Ten internationally established researchers and clinicians participated in this Delphi panel, with a response rate of 80 %, 100 %, and 100 % across three rounds. Consensus was reached on 88.5 % of the statements, resulting in a framework for PT after hospital discharge. Essential handover information should include information on 15 parameters. A core set of outcomes should test exercise capacity, skeletal muscle strength, function in activities of daily living, mobility, quality of life, and pain. PT interventions should include functional exercises, circuit and endurance training, strengthening exercises for limb and respiratory muscles, education on recovery, and a nutritional component. Screening tools to identify impairments in other health domains and referral to specialists are proposed. CONCLUSIONS A consensus-based framework for optimal PT after hospital discharge is proposed. Future research should focus on feasibility testing of this framework, developing risk stratification tools and validating core outcome measures for ICU survivors.
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Affiliation(s)
- M. E. Major
- ACHIEVE—Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- European School of Physiotherapy, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - R. Kwakman
- ACHIEVE—Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - M. E. Kho
- McMaster University, School of Rehabilitation Science, Hamilton, Canada
| | - B. Connolly
- Guy’s & St Thomas’ NHS Foundation Trust and King’s College London, Lane Fox Clinical Respiratory Physiology Research Unit, London, UK
| | - D. McWilliams
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Therapy Services, Birmingham, UK
| | - L. Denehy
- The University of Melbourne, Department of Physiotherapy, Melbourne, Australia
| | - S. Hanekom
- Stellenbosch University, Physiotherapy Division, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - S. Patman
- The University of Notre Dame Australia, School of Physiotherapy, Fremantle, Australia
| | - R. Gosselink
- KU Leuven – University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium
| | - C. Jones
- University of Liverpool, Musculoskeletal Biology, Institute of Ageing & Chronic Disease, Liverpool, UK
| | - F. Nollet
- Academic Medical Center, University of Amsterdam, Department of rehabilitation medicine, PO Box 22660, 1100DD Amsterdam, The Netherlands
| | - D. M. Needham
- Johns Hopkins University Baltimore, Outcomes after Critical Illness and Surgery Group, Baltimore, USA
- Johns Hopkins University School of Medicine Division of Pulmonary and Critical Care Medicine, Baltimore, USA
- Johns Hopkins University School of Medicine Baltimore, Department of Physical Medicine and Rehabilitation, Baltimore, USA
| | - R. H. H. Engelbert
- ACHIEVE—Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Academic Medical Center, University of Amsterdam, Department of rehabilitation medicine, PO Box 22660, 1100DD Amsterdam, The Netherlands
| | - M. van der Schaaf
- ACHIEVE—Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Academic Medical Center, University of Amsterdam, Department of rehabilitation medicine, PO Box 22660, 1100DD Amsterdam, The Netherlands
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Connolly B, O'Neill B, Salisbury L, Blackwood B. Physical rehabilitation interventions for adult patients during critical illness: an overview of systematic reviews. Thorax 2016; 71:881-90. [PMID: 27220357 PMCID: PMC5036250 DOI: 10.1136/thoraxjnl-2015-208273] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 04/11/2016] [Accepted: 04/29/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Physical rehabilitation interventions aim to ameliorate the effects of critical illness-associated muscle dysfunction in survivors. We conducted an overview of systematic reviews (SR) evaluating the effect of these interventions across the continuum of recovery. METHODS Six electronic databases (Cochrane Library, CENTRAL, DARE, Medline, Embase, and Cinahl) were searched. Two review authors independently screened articles for eligibility and conducted data extraction and quality appraisal. Reporting quality was assessed and the Grading of Recommendations Assessment, Development and Evaluation approach applied to summarise overall quality of evidence. RESULTS Five eligible SR were included in this overview, of which three included meta-analyses. Reporting quality of the reviews was judged as medium to high. Two reviews reported moderate-to-high quality evidence of the beneficial effects of physical therapy commencing during intensive care unit (ICU) admission in improving critical illness polyneuropathy/myopathy, quality of life, mortality and healthcare utilisation. These interventions included early mobilisation, cycle ergometry and electrical muscle stimulation. Two reviews reported very low to low quality evidence of the beneficial effects of electrical muscle stimulation delivered in the ICU for improving muscle strength, muscle structure and critical illness polyneuropathy/myopathy. One review reported that due to a lack of good quality randomised controlled trials and inconsistency in measuring outcomes, there was insufficient evidence to support beneficial effects from physical rehabilitation delivered post-ICU discharge. CONCLUSIONS Patients derive short-term benefits from physical rehabilitation delivered during ICU admission. Further robust trials of electrical muscle stimulation in the ICU and rehabilitation delivered following ICU discharge are needed to determine the long-term impact on patient care. This overview provides recommendations for design of future interventional trials and SR. TRIAL REGISTRATION NUMBER CRD42015001068.
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Affiliation(s)
- Bronwen Connolly
- Lane Fox Clinical Respiratory Physiology Research Unit, Guy's and St. Thomas’ NHS Foundation Trust, London, UK
- Centre for Human and Aerospace Physiological Sciences, King's College London, London, UK
- Guy's & St Thomas’ NHS Foundation Trust and King's College London, National Institute of Health Research Biomedical Research Centre, London, UK
| | - Brenda O'Neill
- School of Health Sciences, Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
| | - Lisa Salisbury
- School of Health in Social Science, University of Edinburgh, UK
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Bronagh Blackwood
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
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Orford NR, Lane SE, Bailey M, Pasco JA, Cattigan C, Elderkin T, Brennan-Olsen SL, Bellomo R, Cooper DJ, Kotowicz MA. Changes in Bone Mineral Density in the Year after Critical Illness. Am J Respir Crit Care Med 2016; 193:736-44. [PMID: 26559667 DOI: 10.1164/rccm.201508-1514oc] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
RATIONALE Critical illness may be associated with increased bone turnover and loss of bone mineral density (BMD). Prospective evidence describing long-term changes in BMD after critical illness is needed to further define this relationship. OBJECTIVES To measure the change in BMD and bone turnover markers (BTMs) in subjects 1 year after critical illness compared with population-based control subjects. METHODS We studied adult patients admitted to a tertiary intensive care unit (ICU) who required mechanical ventilation for at least 24 hours. We measured clinical characteristics, BTMs, and BMD during admission and 1 year after ICU discharge. We compared change in BMD to age- and sex-matched control subjects from the Geelong Osteoporosis Study. MEASUREMENTS AND MAIN RESULTS Sixty-six patients completed BMD testing. BMD decreased significantly in the year after critical illness at both femoral neck and anterior-posterior spine sites. The annual decrease was significantly greater in the ICU cohort compared with matched control subjects (anterior-posterior spine, -1.59%; 95% confidence interval, -2.18 to -1.01; P < 0.001; femoral neck, -1.20%; 95% confidence interval, -1.69 to -0.70; P < 0.001). There was a significant increase in 10-year fracture risk for major fractures (4.85 ± 5.25 vs. 5.50 ± 5.52; P < 0.001) and hip fractures (1.57 ± 2.40 vs. 1.79 ± 2.69; P = 0.001). The pattern of bone resorption markers was consistent with accelerated bone turnover. CONCLUSIONS Critically ill individuals experience a significantly greater decrease in BMD in the year after admission compared with population-based control subjects. Their bone turnover biomarker pattern is consistent with an increased rate of bone loss.
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Affiliation(s)
- Neil R Orford
- 1 Intensive Care Unit, University Hospital Geelong.,3 School of Medicine, Deakin University, and.,2 Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Stephen E Lane
- 3 School of Medicine, Deakin University, and.,4 Biostatistics Unit, Barwon Health, Geelong, Australia
| | - Michael Bailey
- 2 Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Julie A Pasco
- 5 Epi-Centre for Healthy Ageing, School of Medicine, Deakin University, Geelong, Australia.,6 Barwon Health, Geelong, Australia.,7 Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Claire Cattigan
- 1 Intensive Care Unit, University Hospital Geelong.,3 School of Medicine, Deakin University, and
| | | | - Sharon L Brennan-Olsen
- 5 Epi-Centre for Healthy Ageing, School of Medicine, Deakin University, Geelong, Australia.,7 Department of Medicine, The University of Melbourne, Melbourne, Australia.,8 Australian Institute for Musculoskeletal Science and Epidemiology Unit for Healthy Ageing, School of Medicine, University of Melbourne, Melbourne, Australia; and.,9 Institute for Health and Ageing, Australian Catholic University, Melbourne, Australia
| | - Rinaldo Bellomo
- 2 Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - David J Cooper
- 2 Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mark A Kotowicz
- 5 Epi-Centre for Healthy Ageing, School of Medicine, Deakin University, Geelong, Australia.,6 Barwon Health, Geelong, Australia.,7 Department of Medicine, The University of Melbourne, Melbourne, Australia
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Affiliation(s)
- Doug Elliott
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Zudin Puthucheary
- Institute of Health and Human Performance, University College London, London, UK
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Singer JP, Lederer DJ, Baldwin MR. Frailty in Pulmonary and Critical Care Medicine. Ann Am Thorac Soc 2016; 13:1394-404. [PMID: 27104873 PMCID: PMC5021078 DOI: 10.1513/annalsats.201512-833fr] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/22/2016] [Indexed: 02/07/2023] Open
Abstract
Conceptualized first in the field of geriatrics, frailty is a syndrome characterized by a generalized vulnerability to stressors resulting from an accumulation of physiologic deficits across multiple interrelated systems. This accumulation of deficits results in poorer functional status and disability. Frailty is a "state of risk" for subsequent disproportionate declines in health status following new exposure to a physiologic stressor. Two predominant models have emerged to operationalize the measurement of frailty. The phenotype model defines frailty as a distinct clinical syndrome that includes conceptual domains such as strength, activity, wasting, and mobility. The cumulative deficit model defines frailty by enumerating the number of age-related things wrong with a person. The biological pathways driving frailty include chronic systemic inflammation, sarcopenia, and neuroendocrine dysregulation, among others. In adults with chronic lung disease, frailty is independently associated with more frequent exacerbations of lung disease, all-cause hospitalization, declines in functional status, and all-cause mortality. In addition, frail adults who become critically ill are more likely develop chronic critical illness or severe disability and have higher in-hospital and long-term mortality rates. The evaluation of frailty appears to provide important prognostic information above and beyond routinely collected measures in adults with chronic lung disease and the critically ill. The study of frailty in these populations, however, requires multipronged efforts aimed at refining clinical assessments, understanding the mechanisms, and developing therapeutic interventions.
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Affiliation(s)
- Jonathan P. Singer
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - David J. Lederer
- Department of Medicine and
- Department of Epidemiology, Columbia University Medical Center, New York, New York; and
| | - Matthew R. Baldwin
- Department of Medicine, Columbia University Medical Center, New York, New York
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Functional Outcomes and Physical Impairments in Pediatric Critical Care Survivors: A Scoping Review. Pediatr Crit Care Med 2016; 17:e247-59. [PMID: 27030932 DOI: 10.1097/pcc.0000000000000706] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Although more children are surviving critical illness, little is known about long-term physical impairment. This scoping review aims to critically appraise existing literature on functional outcome measurement tools, prevalence, and risk factors for physical impairments in pediatric critical care survivors. DATA SOURCES PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature, using a combination of MeSH terms and keywords (critical illness, intensive care, and functional outcomes/status). STUDY SELECTION All human studies reporting functional outcomes in children 0-18 years old admitted to the PICU. Non-English language, adult and preterm infant studies were excluded. DATA SYNTHESIS Three global assessment tools and eight multidimensional measures were used to measure functional outcome in pediatric survivors of critical illness. Rates of acquired functional impairment in a general pediatric intensive care cohort ranged from 10% to 36% at discharge and 10% to 13% after more than 2 years. Risk factors for acquired functional impairment include illness severity, the presence of organ dysfunction, length of ICU stay, and younger age. There is some evidence that physical impairment may be more severe and persistent than psychosocial components. CONCLUSIONS Functional impairment may be persistent in pediatric survivors of critical care. Unfortunately, studies varied largely in measurement timing and tools used. The lack of differentiation between impairment in different functional domains limited the generalizability of data. Further studies using a combination of standardized measures at various time points of the disease process can help establish more comprehensive rates of physical impairment.
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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: 167] [Impact Index Per Article: 18.6] [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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