Comment on Early versus delayed mobilization for in-hospital mortality and health-related quality of life among critically ill patients: a systematic review and meta-analysis (Okada et al., Journal of Intensive Care 2019)

Effects of Mobilization within 72 h of ICU Admission in Critically Ill Patients: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

Previous systematic review and meta-analysis indicates that rehabilitation within a week of intensive care unit (ICU) admission benefits physical function in critically ill patients. This updated systematic review and meta-analysis aim to clarify effects of initiating rehabilitation within 72 h of ICU admission on long-term physical, cognitive, and mental health. We systematically searched the MEDLINE, Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi for randomized controlled trials (RCTs) between April 2019 and November 2022 to add to the previous review. Two investigators independently selected and extracted data. Pooled effect estimates for muscle strength, cognitive function, mental health after discharge, and adverse events were calculated. Evidence certainty was assessed via Grading of Recommendations, Assessment, Development, and Evaluations. Eleven RCTs were included in the meta-analysis. Early rehabilitation may improve muscle strength (three trials; standard mean difference [SMD], 0.16; 95% confidence interval [CI], -0.04-0.36) and cognitive function (two trials; SMD, 0.54; 95% CI, -0.13-1.20). Contrastingly, early mobilization showed limited impact on mental health or adverse events. In summary, initiating rehabilitation for critically ill patients within 72 h may improve physical and cognitive function to prevent post-intensive care syndrome without increasing adverse events. The effect on mental function remains uncertain.

Association between Early Mobilization in the ICU and Psychiatric Symptoms after Surviving a Critical Illness: A Multi-Center Prospective Cohort Study

This is a prospective multicenter cohort study aiming to investigate the association between early mobilization (EM), defined as a rehabilitation level of sitting at the edge of the bed or higher within 72 h of ICU admission, and psychiatric outcome. Consecutive patients, admitted to the ICU for more than 48 h, were enrolled. The primary outcome was the incidence of psychiatric symptoms at 3 months after hospital discharge defined as the presence of any of three symptoms: depression, anxiety, or post-traumatic stress disorder (PTSD). Risk ratio (RR) and multiple logistic regression analysis were used. As a sensitivity analysis, two methods for inverse probability of treatment weighting statistics were performed. Of the 192 discharged patients, 99 (52%) were assessed. The patients who achieved EM had a lower incidence of psychiatric symptoms compared to those who did not (25% vs. 51%, p-value 0.008, odds ratio (OR) 0.27, adjusted p = 0.032). The RR for psychiatric symptoms in the EM group was 0.49 [95% Confidence Interval, 0.29–0.83]. Sensitivity analysis accounting for the influence of death, loss to follow-up (OR 0.28, adjusted p = 0.008), or potential confounders (OR 0.49, adjusted p = 0.046) consistently showed a lower incidence of psychiatric symptoms in the EM group. EM was consistently associated with fewer psychiatric symptoms.

Effects of Mobilization among Critically Ill Patients in the Intensive Care Unit: A Single-center Retrospective Study

Objectives:

This study investigated the effect of early mobilization [EM; physical rehabilitation with the intensity needed to sit on the edge of the bed started within 5 days of intensive care unit (ICU) admission] in relation to improvements in gait independence and other clinical outcomes.

Methods:

This retrospective single-center study evaluated patients aged at least 18 years who stayed in the ICU for at least 48 h and were categorized into EM and late mobilization (LM; physical rehabilitation started more than 5 days after ICU admission) groups. Outcomes were compared after adjusting for 20 background factors by propensity score matching and inverse probability of treatment weighting. The primary outcome was independent gait at discharge. The secondary outcomes were medical costs, 90-day survival, and durations of ICU and hospital stays.

Results:

Of 177 patients, 85 and 92 were enrolled in the EM and LM groups, respectively. Propensity score matching created 37 patient pairs. There was no significant difference in the 90-day survival rate (P=0.308) or medical costs (P=0.054), whereas independent gait at discharge (P=0.025) and duration of hospital stay (P=0.013) differed significantly. Multivariate logistic regression analysis showed that EM was independently associated with independent gait at discharge (P=0.011) and duration of hospital stay (P=0.010) but was not associated with 90-day survival (odds ratio: 2.64, 95% confidence interval: 0.67–13.12, P=0.169).

Conclusions:

Early mobilization in the ICU did not affect 90-day survival and did not lower medical costs but was associated with independent gait at discharge and shorter hospital stays.

Effects of the Intensity and Activity Time of Early Rehabilitation on Activities of Daily Living Dependence in Mechanically Ventilated Patients

OBJECTIVES

The aim of this study was to investigate the association between the Rehabilitation Activity Time score (RATs)-a score based on the level and duration of rehabilitation activities-of ventilated patients in the intensive care unit (ICU) and activities of daily living (ADL) dependence at discharge.

METHODS

This retrospective, single-center study evaluated patients aged >18 years who underwent mechanical ventilation in the ICU for at least 48 h. The patients were categorized into the low- and high-dose rehabilitation groups based on the median RATs. The primary outcome was the rate of ADL dependence at discharge, defined as a Barthel index of <70. The association between low or high doses of rehabilitation and the primary outcome was assessed using multiple logistic regression analysis adjusted by baseline factors.

RESULTS

The rate of ADL dependence at discharge was significantly lower in the high-dose rehabilitation group (low dose 81% vs. high dose 22%, P<0.001). Multivariate analysis showed a significantly lower ADL dependence at discharge among those who received high-dose rehabilitation (P<0.001). Increased RATs during the entire ICU admission period and during ICU admission after meeting the criteria for physiological stability was significantly associated with lower ADL dependence at discharge (P<0.001). Moreover, a higher RATs from low-level activity before meeting the criteria for physiological stability also showed a significant association with lower ADL dependence at discharge (P=0.047).

CONCLUSIONS

ADL dependence was significantly lower among those who underwent high-dose rehabilitation. The RATs was consistently associated with ADL dependence at discharge.

Pathophysiology and Treatment Strategies of Acute Myopathy and Muscle Wasting after Sepsis

Sepsis survivors experience a persistent myopathy characterized by skeletal muscle weakness, atrophy, and an inability to repair/regenerate damaged or dysfunctional myofibers. The origins and mechanisms of this persistent sepsis-induced myopathy are likely complex and multifactorial. Nevertheless, the pathobiology is thought to be triggered by the interaction between circulating pathogens and impaired muscle metabolic status. In addition, while in the hospital, septic patients often experience prolonged periods of physical inactivity due to bed rest, which may exacerbate the myopathy. Physical rehabilitation emerges as a potential tool to prevent the decline in physical function in septic patients. Currently, there is no consensus regarding effective rehabilitation strategies for sepsis-induced myopathy. The optimal timing to initiate the rehabilitation intervention currently lacks consensus as well. In this review, we summarize the evidence on the fundamental pathobiological mechanisms of sepsis-induced myopathy and discuss the recent evidence on in-hospital and post-discharge rehabilitation as well as other potential interventions that may prevent physical disability and death of sepsis survivors.