A physical function test for use in the intensive care unit: validity, responsiveness, and predictive utility of the physical function ICU test (scored)

Incidence and Associated Risk Factors for Falls in Adults Following Critical Illness: An Observational Study

OBJECTIVE

To explore the incidence of falls and associated risk factors in the first year after hospital discharge in survivors of critical illness.

DESIGN

Prospective single-site observational study.

SETTING

University-affiliated mixed ICU.

PATIENTS

One hundred ICU adults who required invasive ventilation for 48 hours and in an ICU for at least 4 days.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

Falls were monitored prospectively for 1 year with completion of monthly falls calendars. Falls data included the number of people who had falls/no falls/recurrent falls, falls rate per person per year, and time to first fall. Fall severity was classified according to the Schwenck classification scheme to examine injurious falls requiring medical intervention. Other outcomes considered included assessments of balance, strength, function, cognition, psychologic health, and health-related quality of life. One hundred participants (31% female) were recruited with a mean age of 58.3 ± 16.2 years, and a median ventilation duration of 6.3 days [4.0-9.1]. Sixty-one percent fell at least once in the first year with the majority sustaining two or more falls (81.4%) and one in four sustained an injurious fall requiring medical attention. The falls incidence rate was 4.4 falls per person-year (95% CI, 3.2-5.9), with the highest incidence occurring less than 3 months after hospital discharge (5.9 falls/person-year [95% CI, 4.4-7.8]). Time to first fall or injurious fall was 36 [11-66] and 95 (95% CI, 40-155) days, respectively. Key risk factors for falls at the time of hospital discharge include comorbidities, higher discharge medications, balance, and muscle strength.

CONCLUSIONS

There was a high falls incidence in ICU survivors. The study findings suggest a critical window may exist within the first 3 months after hospital discharge and the need for screening, pharmacological optimization, and exercise training in this patient group.

Instruments used by physiotherapists to assess functional capacity in hospitalized patients with COVID-19: An online survey

BACKGROUND

Assessing functional capacity in hospitalized patients with COVID-19 may have been neglected due to a great demand for resources at the height of pandemic and the lack of specific assessment instruments for this population.

OBJECTIVES

To identify the instruments used to evaluate functional capacity in COVID-19 patients hospitalized in COVID-19 wards and ICUs and the associations between use of assessment instruments and physiotherapist characteristics METHODS: The survey was conducted using REDCap web-based application, following the Consensus-Based Checklist for Reporting of Survey Studies guidelines. A non-probability recruitment approach aimed at physiotherapists who had treated hospitalized patients with COVID-19 in Brazil. The instruments were classified into four domains: muscle strength, mobility, activities of daily living, and physical performance, as for the International Classification of Functioning, Disability, and Health RESULTS: Overall, 485 physiotherapists responded to the survey, 81.9% of whom used one or more instruments to assess functional capacity. The Medical Research Council (59.6%) and the Six-Minute Walk Test (21.7%) were the most commonly used instruments in COVID-19 wards; the MRC (63.9%) and the Intensive Care Mobility Scale (33.1%), in ICUs. In COVID-19 wards, higher probability of using assessment instruments was associated with being male, having training on COVID-19 management, and working > 50 h/week. In ICUs, having training on COVID-19 management and working in university hospitals were associated with higher probability of using these instruments CONCLUSIONS: Most physiotherapists used one or more instruments to assess functional capacity, assessed more than one physical domain, and used the obtained results to plan interventions.

Inability to Sit-to-Stand in Medical ICUs Survivors: When and Why We Should Care

OBJECTIVES

To investigate the prevalence and association with mortality of inability to perform sit-to-stand independently in critically ill survivors 3 months following medical ICU (MICU) discharge.

DESIGN

Prospective cohort study.

SETTING

Six MICUs at a tertiary care hospital.

PATIENTS

MICU survivors who could sit-to-stand independently before the index hospitalization.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Inability to sit-to-stand (yes/no) was measured at four points following MICU discharge: upon ICU discharge, 1, 2, and 3 months afterward. Mortality was evaluated at 6- and 12-month post-MICU discharge. Among 194 participants, 128 (66%) had inability to sit-to-stand upon MICU discharge. Recovery occurred, with rates decreasing to 50% at 1 month, 38% at 2 months, and 36% at 3 months post-MICU discharge, plateauing at 2 months. Inability to sit-to-stand at 3 months was significantly associated with 21% mortality at 12 months and a 4.2-fold increased risk of mortality (adjusted hazard ratio, 4.2; 95% CI, 1.61-10.99), independent of age, Sequential Organ Failure Assessment score, and ICU-acquired weakness. Notably, improvement in sit-to-stand ability, even from "totally unable" to "able with assistance," correlates with reduced mortality risk.

CONCLUSIONS

Inability to sit-to-stand affects about 36% of MICU survivors even at 3 months post-ICU discharge, highlighting rehabilitation challenges. Revisiting sit-to-stand ability post-ICU discharge is warranted. Additionally, using sit-to-stand as a screening tool for interventions to improve return of its function and mortality is suggested.

Leg Cycle Ergometry in Critically Ill Patients - An Updated Systematic Review and Meta-Analysis

BACKGROUND

Cycle ergometry is a rehabilitation strategy used in the intensive care unit (ICU) which may help mitigate post-ICU impairments. We aimed to systematically review and summarize evidence examining the efficacy and safety of cycle ergometry in the ICU.

METHODS

We included randomized controlled trials (RCTs) of critically ill adults with any diagnosis admitted to the ICU for >24 hours, comparing cycling interventions to control (no cycling). The primary outcome was physical function, using a hierarchical approach to standardize this outcome across trials. We performed random-effects meta-analyses and assessed the certainty of effect estimates using the Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

We included 33 RCTs that enrolled 3274 patients. Cycling may improve physical function at ICU discharge (12 RCTs, 1291 patients, standardized mean difference [SMD], 0.33 [95% confidence interval (CI), 0.05 to 0.62], low certainty) and posthospital discharge (8 RCTs, 865 patients, SMD, 0.23, [95% CI, 0.04 to 0.42], low certainty). Cycling may decrease ICU length of stay (29 RCTs, 2575 patients, mean difference [MD], 1.06 days fewer [95% CI, 0.33 to 1.80 days fewer], low certainty) and probably decreases hospital length of stay (22 RCTs, 2060 patients, MD, 1.48 days fewer [95% CI, 0.47 to 2.49 days fewer], moderate certainty). Cycling may have no effect on ICU mortality (17 RCTs, 2039 patients, risk ratio, 12 fewer deaths per 1000 [95% CI, 43 fewer to 23 more], low certainty). The pooled rate of adverse events in the intervention group was 1% (11 RCTs, 4623 sessions, [95% CI, 0 to 2%], low certainty) and in the comparison group, 2% (6 RCTs, 3365 sessions, [95% CI, 0 to 5%], low certainty).

CONCLUSIONS

In this meta-analysis, we found that cycling with critically ill patients may improve physical function at ICU discharge and after hospital discharge, may reduce ICU length of stay, and probably reduces hospital length of stay, with no effect on other outcomes including mortality. We observed low to very low certainty of evidence for all but one outcome of interest. Adverse events were uncommon. (PROSPERO number, CRD 42018092132.).

Mitochondrial DNA in plasma and long-term physical recovery of critically ill patients: an observational study

BACKGROUND

Post-intensive care syndrome (PICS) poses a notable public health concern, with survivors of critical illness experiencing long-term physical, psychological, and cognitive challenges. Mitochondrial dysfunction has gained attention for its potential involvement in PICS. However, the long-term impact of mitochondrial status on patient recovery remains uncertain. A single-centre retrospective analysis was conducted in Leeuwarden, the Netherlands, between May and November 2019, within a mixed ICU survivor cohort. Patients were assessed for mitochondrial markers (mtDNA damage represented by the presence of mtDNA fragmentation and mitochondrial DNA levels evaluated by the ratio of mtDNA and nuclear DNA), clinical factors, and long-term outcomes measured by the physical functioning (PF) domain of health-related quality of life.

RESULTS

A total of 43 patients were included in this study divided into recovery and non-recovery groups based on age-adjusted PF scores at 12 months post-ICU. Nineteen patients scored below these thresholds. No significant differences in mitochondrial markers between groups were identified. Furthermore, no significant correlations were found between mtDNA levels and mtDNA damage at baseline and 12 months with PF scores. However, mtDNA levels decreased over time in the recovery (p-value <  < 0.01) and non-recovery groups (p-value < 0.01).

CONCLUSION

No significant correlation was found between mitochondrial markers and physical functioning scores. This study underscores the multifactorial nature of PICS and the need for a comprehensive understanding of its metabolic and cellular components. While mitochondrial markers may play a role in PICS, they operate within a framework influenced by various factors. This exploratory study serves as a foundation for future investigations aimed at developing targeted interventions to enhance the quality of life for ICU survivors grappling with PICS.

Early In-Bed Cycle Ergometry With Critically Ill, Mechanically Ventilated Patients: Statistical Analysis Plan for CYCLE (Critical Care Cycling to Improve Lower Extremity Strength), an International, Multicenter, Randomized Clinical Trial

BACKGROUND

Survivors of critical illness are at risk of developing physical dysfunction following intensive care unit (ICU) discharge. ICU-based rehabilitation interventions, such as early in-bed cycle ergometry, may improve patients' short-term physical function.

OBJECTIVE

Before unblinding and trial database lock, we describe a prespecified statistical analysis plan (SAP) for the CYCLE (Critical Care Cycling to Improve Lower Extremity Strength) randomized controlled trial (RCT).

METHODS

CYCLE is a 360-patient, international, multicenter, open-label, parallel-group RCT (1:1 ratio) with blinded primary outcome assessment at 3 days post-ICU discharge. The principal investigator and statisticians of CYCLE prepared this SAP with approval from the steering committee and coinvestigators. The SAP defines the primary and secondary outcomes (including adverse events) and describes the planned primary, secondary, and subgroup analyses. The primary outcome of the CYCLE trial is the Physical Function Intensive Care Unit Test-scored (PFIT-s) at 3 days post-ICU discharge. The PFIT-s is a reliable and valid performance-based measure. We plan to use a frequentist statistical framework for all analyses. We will conduct a linear regression to evaluate the primary outcome, incorporating randomization as an independent variable and adjusting for age (≥65 years versus <65 years) and center. The regression results will be reported as mean differences in PFIT-s scores with corresponding 95% CIs and P values. We consider a 1-point difference in PFIT-s score to be clinically important. Additionally, we plan to conduct 3 subgroup analyses: age (≥65 years versus <65 years), frailty (Baseline Clinical Frailty Scale ≥5 versus <5), and sex (male versus female).

RESULTS

CYCLE was funded in 2017, and enrollment was completed in May 2023. Data analyses are complete, and the first results were submitted for publication in 2024.

CONCLUSIONS

We developed and present an SAP for the CYCLE RCT and will adhere to it for all analyses. This study will add to the growing body of evidence evaluating the efficacy and safety of ICU-based rehabilitation interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03471247; https://clinicaltrials.gov/ct2/show/NCT03471247 and NCT02377830; https://clinicaltrials.gov/ct2/show/NCT02377830.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/54451.

Early In-Bed Cycle Ergometry in Mechanically Ventilated Patients

BACKGROUND

Critical illness requiring invasive mechanical ventilation can precipitate important functional disability, contributing to multidimensional morbidity following admission to an intensive care unit (ICU). Early in-bed cycle ergometry added to usual physiotherapy may mitigate ICU-acquired physical function impairment.

METHODS

We randomly assigned 360 adult ICU patients undergoing invasive mechanical ventilation to receive 30 minutes of early in-bed Cycling + Usual physiotherapy (n=178) or Usual physiotherapy alone (n=182). The primary outcome was the Physical Function ICU Test-scored (PFIT-s) at 3 days after discharge from the ICU (the score ranges from 0 to 10, with higher scores indicating better function).

RESULTS

Cycling began within a median (interquartile range) of 2 (1 to 3) days of starting mechanical ventilation; patients received 3 (2 to 5) cycling sessions for a mean (±standard deviation) of 27.2 ± 6.6 minutes. In both groups, patients started Usual physiotherapy within 2 (2 to 4) days of mechanical ventilation and received 4 (2 to 7) Usual physiotherapy sessions. The duration of Usual physiotherapy was 23.7 ± 15.1 minutes in the Cycling + Usual physiotherapy group and 29.1 ± 13.2 minutes in the Usual physiotherapy group. No serious adverse events occurred in either group. Among survivors, the PFIT-s at 3 days after discharge from the ICU was 7.7 ± 1.7 in the Cycling + Usual physiotherapy group and 7.5 ± 1.7 in the Usual physiotherapy group (absolute difference, 0.23 points; 95% confidence interval, -0.19 to 0.65; P=0.29).

CONCLUSIONS

Among adults receiving mechanical ventilation in the ICU, adding early in-bed Cycling to usual physiotherapy did not improve physical function at 3 days after discharge from the ICU compared with Usual physiotherapy alone. Cycling did not cause any serious adverse events. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov numbers, NCT03471247 [full randomized clinical trial] and NCT02377830 [CYCLE Vanguard 46-patient internal pilot].).

The impact of early rehabilitation in intensive care unit for COVID-19 patients

PURPOSE

To evaluate the impact of early rehabilitation in intensive care unit (ICU) on the survival and functional outcomes of COVID-19 patients admitted to ICU at acute phase.

MATERIALS AND METHODS

We conducted a prospective quasi-experimental study including 346 eligible COVID-19 patients from all admitted cases in an ICU in Vietnam, divided into three groups: no rehabilitation (n = 32), late rehabilitation (n = 109), and early rehabilitation (n = 205). Baseline characteristics and survival information of patient were collected with BORG-CR10 scale and PFIT; the data were collected at different time points: before intervention, when switching to oxygen-therapy, and at discharge.

RESULTS

The control group (patients not using rehabilitation therapy) has worse survival than both early rehabilitation group (hazard ratio [HR] 0.553; 95% confidence interval [CI] 0.380-0.806; p value < 0.001) and late rehabilitation group (HR 0.374; CI 0.235-0.594; p value < 0.001). Regarding functional improvement, during the first five days, rehabilitation did not make a significant impact on the patients (p value > 0.05), however if continued from day 5 to day 20, the early-rehabilitation patients obtained a statistically significant improvement for BORG-CR10 (p value < 0.01). No clear association was found for PFIT (p value > 0.05).

CONCLUSION

The research emphasises the benefits of the early rehabilitation in ICU for COVID-19 patients.

Safety and quality of parenteral nutrition: Areas for improvement and future perspectives

PURPOSE

This article is based on presentations and discussions held at the International Safety and Quality of Parenteral Nutrition (PN) Summit (held November 8-10, 2021, at Charleston, SC, and Bad Homburg, Germany) and aims to raise awareness concerning unresolved issues associated with the PN process and potential future directions, including a greater emphasis on patients' perspectives and the role of patient support.

SUMMARY

Ensuring that every patient in need receives adequate PN support remains challenging. It is important to have a standardized approach to identify nutritional risk and requirements using validated nutritional screening and assessment tools. Gaps between optimal and actual clinical practices need to be identified and closed, and responsibilities in the nutrition support team clarified. Use of modern technology opens up opportunities to decrease workloads or liberate resources, allowing a more personalized care approach. Patient-centered care has gained in importance and is an emerging topic within clinical nutrition, in part because patients often have different priorities and concerns than healthcare professionals. Regular assessment of health-related quality of life, functional outcomes, and/or overall patient well-being should all be performed for PN patients. This will generate patient-centric data, which should be integrated into care plans. Finally, communication and patient education are prerequisites for patients' commitment to health and for fostering adherence to PN regimes.

CONCLUSION

Moving closer to optimal nutritional care requires input from healthcare professionals and patients. Patient-centered care and greater emphasis on patient perspectives and priorities within clinical nutrition are essential to help further improve clinical nutrition.

Physical function and activity of patients after open abdominal surgery: a prospective cohort study comparing the clinimetric properties of two outcome measures

OBJECTIVES

To measure and compare the clinimetric properties of the Chelsea Critical Care Physical Assessment (CPAx) and Physical Function in Intensive Care Test-scored (PFIT-s) for assessment of physical function and activity.

DESIGN

Prospective cohort design using crossover-randomisation of the sequence in which participants were assessed with CPAx and PFIT-s.

SETTING

Surgical and transplant intensive care units (ICU) in an academic hospital.

PARTICIPANTS

Adults who underwent elective open abdominal surgery. Consecutive sampling was used to enrol 69 participants.

INTERVENTIONS

Physical function and activity were assessed on ICU days one, three, five and at ICU discharge using the CPAx and PFIT-s in random order.

MAIN OUTCOME MEASURES

Responsiveness to change, minimal clinically important difference (MCID), floor and ceiling effect, and convergent validity.

RESULTS

CPAx demonstrated a large responsiveness (effect size index (ESI)= 0.83) and PFIT-s moderate responsiveness (ESI=0.73) to change in scores. MCID for CPAx was 2.1 (standard error of measurement (SEM) 1.1) and for PFIT-s 0.6 (SEM=0.3). CPAx had no floor effect and a small ceiling effect (9%, n = 6) at ICU discharge compared to 2% (n = 1) floor and 48% (n = 32) ceiling effects of PFIT-s. Moderate convergent validity was found for both tools at ICU admission (n = 67, r = 0.62, p < 0.001) and discharge (n = 67, r = 0.51, p < 0.001).

CONCLUSION

CPAx is most responsive to changes in physical function and activity scores, has no floor and limited ceiling effects and moderate convergent validity, and is recommended for similar cohorts. CONTRIBUTION OF THE PAPER.

Early Mobilization and Rehabilitation of Critically-Ill Patients

Post-intensive care unit (ICU) syndrome may occur after ICU treatment and includes ICU-acquired weakness (ICU-AW), cognitive decline, and mental problems. ICU-AW is muscle weakness in patients treated in the ICU and is affected by the period of mechanical ventilation. Diaphragmatic weakness may also occur because of respiratory muscle unloading using mechanical ventilators. ICU-AW is an independent predictor of mortality and is associated with longer duration of mechanical ventilation and hospital stay. Diaphragm weakness is also associated with poor outcomes. Therefore, pulmonary rehabilitation with early mobilization and respiratory muscle training is necessary in the ICU after appropriate patient screening and evaluation and can improve ICU-related muscle weakness and functional deterioration.

The effects of inspiratory muscle training on physical function in critically ill adults: Protocol for a systematic review and meta-analysis

INTRODUCTION

Inspiratory muscle training (IMT) is one possible strategy to ameliorate respiratory muscle weakness due to invasive mechanical ventilation. Recent systematic reviews have focused on respiratory outcomes with minimal attention to physical function. The newest systematic review searched the literature until September 2017 and a recent preliminary search identified 5 new randomized controlled trials focusing on IMT in critical care. As such, a new systematic review is warranted to summarize the current body of evidence and to investigate the effect of IMT on physical function in critical care.

MATERIALS AND METHODS

We will search for three main concepts ("critical illness", "inspiratory muscle training", "RCT") across six databases from their inception (MEDLINE, EMBASE, Emcare, AMED, CINAHL, CENTRAL) and ClinicalTrials.gov. Two reviewers will independently screen titles, abstracts, and full texts for eligibility using the Covidence web-based software. Eligible studies must include: (1) adult (≥18 years) patients admitted to the intensive care unit (ICU) who required invasive mechanical ventilation for ≥24 hours, (2) an IMT intervention using a threshold device with the goal of improving inspiratory muscle strength, with or without usual care, and (3) randomized controlled trial design. The primary outcome of interest will be physical function. We will use the Cochrane Risk of Bias Tools (ROB2) and will assess the quality of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. This protocol has been reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA- P) guidelines and is registered with the International Prospective Register of Systematic Reviews (PROSPERO).

CONCLUSION

Results will summarize the body of evidence of the effect of IMT on physical function in critically ill patients. We will submit our findings to a peer-reviewed journal and share our results at conferences.

Association Between Mobilization Level And Activity of Daily Living Independence in Critically Ill Patients

OBJECTIVE

To examine the association between the mobilization level during intensive care unit (ICU) admission and independence in activity of daily living (ADL), defined as Barthel Index (BI)≥70.

METHODS

This was a post-hoc analysis of the EMPICS study involving nine hospitals. Consecutive patients who spend >48 hours in the ICU were eligible for inclusion. Mobilization was performed at each hospital according to the shared protocol and the highest ICU mobility score (IMS) during the ICU stay, baseline characteristics, and BI at hospital discharge. Multiple logistic regression analysis, adjusted for baseline characteristics, was used to deter-mine the association between the highest IMS (using the receiver operating characteristic [ROC]) and ADL.

RESULTS

Of the 203 patients, 143 were assigned to the ADL independence group and 60 to the ADL dependence group. The highest IMS score was significantly higher in the ADL independence group than in the dependence group and was a predictor of ADL independence at hospital discharge (odds ratio, 1.22; 95% confidence interval, 1.07-1.38; adjusted p=0.002). The ROC cutoff value for the highest IMS was 6 (specificity, 0.67; sensitivity, 0.70; area under the curve, 0.69).

CONCLUSION

These results indicate that, in patients who were in the ICU for more than 48 hours, that patients with good function in the ICU also exhibit good function upon discharge. However, prospective, multicenter trials are needed to confirm this conclusion.

Exercise testing to guide safe discharge from hospital in COVID-19: a scoping review to identify candidate tests

OBJECTIVES

We aimed to identify exercise tests that have been validated to support a safe discharge to home in patients with or without COVID-19.

STUDY DESIGN

Scoping review, using PRISMA-ScR reporting standards. Medline, PubMed, AMED, Embase, CINAHL and LitCovid databases were searched between 16 and 22 February 2021, with studies included from any publication date up to and including the search date.

INTERVENTION

Short exercise tests.

PRIMARY OUTCOME MEASURES

Safe discharge from hospital, readmission rate, length of hospital stay, mortality. Secondary outcomes measures: safety, feasibility and reliability.

RESULTS

Of 1612 original records screened, 19 studies were included in the analysis. These used a variety of exercise tests in patients with chronic obstructive pulmonary disease, suspected pulmonary embolism and pneumocystis carinii pneumonia, heart failure or critical illness. Only six studies had examined patients with COVID-19, of these two were still recruiting to evaluate the 1 min sit-to-stand test and the 40-steps test. There was heterogeneity in patient populations, tests used and outcome measures. Few exercise tests have been validated to support discharge decisions. There is currently no support for short exercise tests for triage of care in patients with COVID-19.

CONCLUSIONS

Further research is needed to aid clinical decision-making at discharge from hospital.

Activin A level is associated with physical function in critically ill patients

BACKGROUND

Activin A is a potent negative regulator of muscle mass elevated in critical illness. It is unclear whether muscle strength and physical function in critically ill humans are associated with elevated activin A levels.

OBJECTIVES

The objective of this study was to investigate the relationship between serum activin A levels, muscle strength, and physical function at discharge from the intensive care unit (ICU) and hospital.

METHODS

Thirty-six participants were recruited from two tertiary ICUs in Melbourne, Australia. Participants were included if they were mechanically ventilated for >48 h and expected to have a total ICU stay of >5 days. The primary outcome measure was the Six-Minute Walk Test distance at hospital discharge. Secondary outcome measures included handgrip strength, Medical Research Council Sum Score, Physical Function ICU Test Scored, Six-Minute Walk Test, and Timed Up and Go Test assessed throughout the hospital admission. Total serum activin A levels were measured daily in the ICU.

RESULTS

High peak activin A was associated with worse Six-Minute Walk Test distance at hospital discharge (linear regression coefficient, 95% confidence interval, p-value: -91.3, -154.2 to -28.4, p = 0.007, respectively). Peak activin A concentration was not associated with the secondary outcome measures.

CONCLUSIONS

Higher peak activin A may be associated with the functional decline of critically ill patients. Further research is indicated to examine its potential as a therapeutic target and a prospective predictor for muscle wasting in critical illness.

STUDY REGISTRATION

ACTRN12615000047594.

Linking Intensive Care Unit functional scales to the International Classification of Functioning: proposal of a new assessment approach

BACKGROUND

There are several tools to assess functional and physical status in critical ill patients. These tools can guide rehabilitation strategies in Intensive care units (ICU). However, they are not standardized, and this can compromise their applicability. The aim of the study is to identify common contents between International Classification of Functioning, Disability and Health (ICF) and Medical Research Council sum score (MRC-ss), Functional Status Score for the ICU (FSS-ICU), and Physical Function in ICU Test-scored (PFIT-s). As well as to propose a new assessment approach based on the ICF to ICU patients.

METHODS

Pilot cross-sectional study. ICU in-patients, both genders, aged between 50 and 75 years were assessed with MRC-ss, FSS-ICU, PFIT-s and the linking rules used were proposed by Cieza et al. The inter-rater agreement for the linking process was performed using the Kappa coefficient.

RESULTS

The ICF categories identified in the tools covered a total of 14 items. Common contents were identified in 13 of the 14 and two were related to body functions, six to body structures and five to activities and participation. The inter-rater agreement was considered substantial for the linking of MRC-ss (k = 0.665) and PFIT-s (k = 0.749) to the ICF, and almost perfect for the FSS-ICU (k = 0.832).

CONCLUSIONS

This study synthesizes and categorizes commonly used tools and presents a new proposal based on the ICF to guide future studies. The proposed model combines the ICF with the contents of the most relevant instruments used in critical care.

Critical Care Cycling to Improve Lower Extremity Strength (CYCLE): protocol for an international, multicentre randomised clinical trial of early in-bed cycling for mechanically ventilated patients

INTRODUCTION

In-bed leg cycling with critically ill patients is a promising intervention aimed at minimising immobility, thus improving physical function following intensive care unit (ICU) discharge. We previously completed a pilot randomised controlled trial (RCT) which supported the feasibility of a large RCT. In this report, we describe the protocol for an international, multicentre RCT to determine the effectiveness of early in-bed cycling versus routine physiotherapy (PT) in critically ill, mechanically ventilated adults.

METHODS AND ANALYSIS

We report a parallel group RCT of 360 patients in 17 medical-surgical ICUs and three countries. We include adults (≥18 years old), who could ambulate independently before their critical illness (with or without a gait aid), ≤4 days of invasive mechanical ventilation and ≤7 days ICU length of stay, and an expected additional 2-day ICU stay, and who do not fulfil any of the exclusion criteria. After obtaining informed consent, patients are randomised using a web-based, centralised system to either 30 min of in-bed cycling in addition to routine PT, 5 days per week, up to 28 days maximum, or routine PT alone. The primary outcome is the Physical Function ICU Test-scored (PFIT-s) at 3 days post-ICU discharge measured by assessors blinded to treatment allocation. Participants, ICU clinicians and research coordinators are not blinded to group assignment. Our sample size estimate was based on the identification of a 1-point mean difference in PFIT-s between groups.

ETHICS AND DISSEMINATION

Critical Care Cycling to improve Lower Extremity (CYCLE) is approved by the Research Ethics Boards of all participating centres and Clinical Trials Ontario (Project 1345). We will disseminate trial results through publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT03471247 (Full RCT); NCT02377830 (CYCLE Vanguard 46 patient internal pilot).

Feasibility and safety of the 30-second sit-to-stand test delivered via telehealth: An observational study

INTRODUCTION

Exercise testing is essential to determine the safety and efficacy of prescribing exercise. Limited evidence exists to support remotely supervised exercise testing in oncology literature.

OBJECTIVE

To determine the feasibility, safety, and convergent validity of the 30-second sit-to-stand test (30STS) delivered via telehealth in an oncology population. Exploratory analyses informed remote test feasibility according to participant and treatment characteristics.

DESIGN

Cross-sectional, observational study.

SETTING

Telehealth outpatient clinic, tertiary metropolitan oncology hospital.

PARTICIPANTS

Thirty-two consecutive outpatients attending telehealth exercise appointments were screened for inclusion.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A pre-test safety screening questionnaire included the Australia-modified Karnofsky Performance Status (AKPS) and Clinical Frailty Scale (CFS). Following one practice, one 30STS test was completed using a standardized protocol modified for telehealth assessment. Secondary measures: International Physical Activity Questionnaire-Short Form (IPAQ-SF) and pre/post-test Borg Rating of Perceived Exertion (RPE).

RESULTS

Thirty participants were deemed as being safe using the screening questionnaire and completed the remote 30STS. Participants were a median (interquartile range [IQR]) 62.5 (51.8 to 66.5) years old, 59% male, 72% undergoing cancer treatment, 34% with metastatic disease, and 56% met current exercise guidelines. Moderate correlation was found between 30STS and IPAQ-SF (rho = 0.49, p = .006), providing evidence of convergent validity. Correlations between 30STS and AKPS (rho = 0.26, p = .161), and CFS (rho = -0.23, p = .214), were fair. Chair-height standardization was poor (range 43 to 60 cm). The clinician could visualize the participant's whole body in 2 of 30 tests. No significant difference in test performance was found for participants with metastatic disease, higher age, or body mass index. No adverse events occurred.

CONCLUSION

With screening, the 30STS, performed by telehealth, is a safe and feasible measure of function and lower limb strength. Telehealth exercise testing presents challenges in standardizing the environment and ensuring participant safety. Minimal space and equipment requirements and moderate convergent validity with physical activity provide good clinical utility in this setting.

Validity, inter-rater reliability, and feasibility of the Chelsea Physical Assessment Tool for assessing physical function in post-acute COVID-19 patients: A cross-sectional study

BACKGROUND

Various tools have been created to measure physical function during intensive care unit (ICU) stay and after ICU discharge, but those have not been validated in coronavirus 2019 (COVID-19) patients. There is a need for a reliable, valid and feasible tool to define the rehabilitation needs of post-ICU COVID-19 patients entering the acute wards and then rehabilitation clinics.

OBJECTIVE

This study aims to investigate the validity, inter-rater reliability and feasibility of Chelsea Physical Assessment Tool (CPAx) in assessing the functional status of COVID-19 patients after discharge from the ICU.

METHODS

Demographic and clinical characteristics of the patients were recorded. Patients were evaluated using the modified Medical Research Council (MRC) dyspnea scale, Functional Oral Intake Scale, Glasgow Coma Scale, CPAx, Barthel Index, Katz Index and MRC sum score, measurements of grip strength obtained by dynamometer, the 5 time sit-to-stand test and 30 seconds and sit-to-stand test. CPAx and the other functional assessment tools were administered to 16 patients within 48 hours following ICU discharge. For inter-rater reliability, another physiatrist independently re-assessed the patients. MRC sum score, Barthel and Katz indexes were used to assess construct validity of CPAx. The discriminative validity of CPAx was determined by its ability to differentiate between patients with and without ICU acquired muscle weakness based on MRC sum score. The intra-class correlation coefficients (ICC) were calculated to determine inter-rater reliability for total scores of the functional assessment tools. Cohen's Kappa (κ) coefficient and weighed Kappa (κw) were calculated to determine inter-rater reliability of individual CPAx items. Ceiling and flooring effects were calculated by percentage frequency of lowest or highest possible score achieved. The number and percentages of the patients who were able to complete each tool were calculated to assess feasibility.

RESULTS

The CPAx score was strongly correlated with MRC sum score (rho: 0.83), Barthel Index (rho: 0.87) and Katz Index (rho: 0.89) (p< 0.001) showing construct validity. Area under the ROC curve demonstrated that cut off score for CPAx was ⩽ 12 to discriminate patients with MRC sum score < 48, with a sensitivity and a specificity of 100% and 63%, respectively (AUC = 0.859, p< 0.001). ICC was high for CPAx, MRC sum score, Barthel and Katz indexes, Glasgow Coma Scale, and hand grip strength measurement, with the highest value observed for CPAx (ICC, 0.96; 95% confidence interval (CI), 0.71-0.98). κ and κw analysis showed good to excellent inter-rater reliability for individual CPAx items. No floor or ceiling effect was observed at CPAx while floor effect was observed at Barthel Index scores (25%) and Katz Index scores (37.5%). All patients could be evaluated using CPAx while less were physically able to complete the 5 time sit-to-stand, 30 seconds sit-to-stand tests (n= 4) and MRC sum score (n= 14).

CONCLUSION

CPAx is a valid, reliable, and feasible tool to assess the physical functional state in COVID-19 patients following discharge from the ICU.

Research interrupted: applying the CONSERVE 2021 Statement to a randomized trial of rehabilitation during critical illness affected by the COVID-19 pandemic

RATIONALE

The COVID-19 pandemic disrupted non-COVID critical care trials globally as intensive care units (ICUs) prioritized patient care and COVID-specific research. The international randomized controlled trial CYCLE (Critical Care Cycling to Improve Lower Extremity Strength) was forced to halt recruitment at all sites in March 2020, creating immediate challenges. We applied the CONSERVE (CONSORT and SPIRIT Extension for RCTs Revised in Extenuating Circumstance) statement as a framework to report the impact of the pandemic on CYCLE and describe our mitigation approaches.

METHODS

On March 23, 2020, the CYCLE Methods Centre distributed a standardized email to determine the number of patients still in-hospital and those requiring imminent 90-day endpoint assessments. We assessed protocol fidelity by documenting attempts to provide the in-hospital randomized intervention (cycling or routine physiotherapy) and collect the primary outcome (physical function 3-days post-ICU discharge) and 90-day outcomes. We advised sites to prioritize data for the study's primary outcome. We sought feedback on pandemic barriers related to trial procedures.

RESULTS

Our main Methods Centre mitigation strategies included identifying patients at risk for protocol deviations, communicating early and frequently with sites, developing standardized internal tools focused on high-risk points in the protocol for monitoring patient progress, data entry, and validation, and providing guidance to conduct some research activities remotely. For study sites, our strategies included determining how institutional pandemic research policies applied to CYCLE, communicating with the Methods Centre about capacity to continue any part of the research, and developing contingency plans to ensure the protocol was delivered as intended. From 15 active sites (12 Canada, 2 US, 1 Australia), 5 patients were still receiving the study intervention in ICUs, 6 required primary outcomes, and 17 required 90-day assessments. With these mitigation strategies, we attempted 100% of ICU interventions, 83% of primary outcomes, and 100% of 90-day assessments per our protocol.

CONCLUSIONS

We retained all enrolled patients with minimal missing data using several time-sensitive strategies. Although CONSERVE recommends reporting only major modifications incurred by extenuating circumstances, we suggest that it also provides a helpful framework for reporting mitigation strategies with the goal of improving research transparency and trial management.

TRIAL REGISTRATION

NCT03471247. Registered on March 20, 2018.

Intensive care unit-acquired weakness: From molecular mechanisms to its impact in COVID-2019

Intensive Care Unit-Acquired Weakness (ICU-AW) is a generalized and symmetric neuromuscular dysfunction associated with critical illness and its treatments. Its incidence is approximately 80% in intensive care unit patients, and it manifests as critical illness polyneuropathy, critical illness myopathy, and muscle atrophy. Intensive care unit patients can lose an elevated percentage of their muscle mass in the first days after admission, producing short- and long-term sequelae that affect patients’ quality of life, physical health, and mental health. In 2019, the world was faced with coronavirus disease 2019 (COVID-19), caused by the acute respiratory syndrome coronavirus 2. COVID-19 produces severe respiratory disorders, such as acute respiratory distress syndrome, which increases the risk of developing ICU-AW. COVID-19 patients treated in intensive care units have shown early diffuse and symmetrical muscle weakness, polyneuropathy, and myalgia, coinciding with the clinical presentation of ICU-AW. Besides, these patients require prolonged intensive care unit stays, invasive mechanical ventilation, and intensive care unit pharmacological therapy, which are risk factors for ICU-AW. Thus, the purposes of this review are to discuss the features of ICU-AW and its effects on skeletal muscle. Further, we will describe the mechanisms involved in the probable development of ICU-AW in severe COVID-19 patients.

The sit-to-stand test as a patient-centered functional outcome for critical care research: a pooled analysis of five international rehabilitation studies

BACKGROUND

With ICU mortality rates decreasing, it is increasingly important to identify interventions to minimize functional impairments and improve outcomes for survivors. Simultaneously, we must identify robust patient-centered functional outcomes for our trials. Our objective was to investigate the clinimetric properties of a progression of three outcome measures, from strength to function.

METHODS

Adults (≥ 18 years) enrolled in five international ICU rehabilitation studies. Participants required ICU admission were mechanically ventilated and previously independent. Outcomes included two components of the Physical Function in ICU Test-scored (PFIT-s): knee extensor strength and assistance required to move from sit to stand (STS); the 30-s STS (30 s STS) test was the third outcome. We analyzed survivors at ICU and hospital discharge. We report participant demographics, baseline characteristics, and outcome data using descriptive statistics. Floor effects represented ≥ 15% of participants with minimum score and ceiling effects ≥ 15% with maximum score. We calculated the overall group difference score (hospital discharge score minus ICU discharge) for participants with paired assessments.

RESULTS

Of 451 participants, most were male (n = 278, 61.6%) with a median age between 60 and 66 years, a mean APACHE II score between 19 and 24, a median duration of mechanical ventilation between 4 and 8 days, ICU length of stay (LOS) between 7 and 11 days, and hospital LOS between 22 and 31 days. For knee extension, we observed a ceiling effect in 48.5% (160/330) of participants at ICU discharge and in 74.7% (115/154) at hospital discharge; the median [1st, 3rd quartile] PFIT-s difference score (n = 139) was 0 [0,1] (p < 0.05). For STS assistance, we observed a ceiling effect in 45.9% (150/327) at ICU discharge and in 77.5% (79/102) at hospital discharge; the median PFIT-s difference score (n = 87) was 1 [0, 2] (p < 0.05). For 30 s STS, we observed a floor effect in 15.0% (12/80) at ICU discharge but did not observe a floor or ceiling effect at hospital discharge. The median 30 s STS difference score (n = 54) was 3 [1, 6] (p < 0.05).

CONCLUSION

Among three progressive outcome measures evaluated in this study, the 30 s STS test appears to have the most favorable clinimetric properties to assess function at ICU and hospital discharge in moderate to severely ill participants.

Improving physical function of patients following intensive care unit admission (EMPRESS): protocol of a randomised controlled feasibility trial

INTRODUCTION

Physical rehabilitation delivered early following admission to the intensive care unit (ICU) has the potential to improve short-term and long-term outcomes. The use of supine cycling together with other rehabilitation techniques has potential as a method of introducing rehabilitation earlier in the patient journey. The aim of the study is to determine the feasibility of delivering the designed protocol of a randomised clinical trial comparing a protocolised early rehabilitation programme including cycling with usual care. This feasibility study will inform a larger multicentre study.

METHODS AND ANALYSIS

90 acute care medical patients from two mixed medical-surgical ICUs will be recruited. We will include ventilated patients within 72 hours of initiation of mechanical ventilation and expected to be ventilated a further 48 hours or more. Patients will receive usual care or usual care plus two 30 min rehabilitation sessions 5 days/week.Feasibility outcomes are (1) recruitment of one to two patients per month per site; (2) protocol fidelity with >75% of patients commencing interventions within 72 hours of mechanical ventilation, with >70% interventions delivered; and (3) blinded outcome measures recorded at three time points in >80% of patients. Secondary outcomes are (1) strength and function, the Physical Function ICU Test-scored measured on ICU discharge; (2) hospital length of stay; and (3) mental health and physical ability at 3 months using the WHO Disability Assessment Schedule 2. An economic analysis using hospital health services data reported with an embedded health economic study will collect and assess economic and quality of life data including the Hospital Anxiety and Depression Scales core, the Euroqol-5 Dimension-5 Level and the Impact of Event Score.

ETHICS AND DISSEMINATION

The study has ethical approval from the South Central Hampshire A Research Ethics Committee (19/SC/0016). All amendments will be approved by this committee. An independent trial monitoring committee is overseeing the study. Results will be made available to critical care survivors, their caregivers, the critical care societies and other researchers.

TRIAL REGISTRATION NUMBER

NCT03771014.

Brazilian version of the Critical Care Functional Rehabilitation Outcome Measure: translation, cross-cultural adaptation and evaluation of clinimetric properties

OBJECTIVE

To translate, crossculturally adapt and evaluate the clinimetric properties of the Critical Care Functional Rehabilitation Outcome Measure for evaluating the functionality of patients admitted to intensive care units in Brazil.

METHODS

The process of translation and cross-cultural adaptation involved the following steps: initial translation, synthesis, back-translation, expert committee review and pretesting. The intra- and interrater reliability and agreement were analyzed between two physical therapists who evaluated the same group of patients (n = 35). The evaluations were performed by each therapist independently and blinded to the score assigned by the other professional. The qualitative analysis was performed by the review committee, and the experts adapted and synthesized the Portuguese translation of the Critical Care Functional Rehabilitation Outcome Measure.

RESULTS

There was agreement between the initial Brazilian translations of the Critical Care Functional Rehabilitation Outcome Measure scale. The conceptual, idiomatic, semantic and experimental equivalences between the original and translated versions were assessed, resulting in the final Brazilian version of the scale, called the Medida de Resultado da Reabilitação Funcional em Cuidados Intensivos. The evaluation of the clinimetric properties showed evidence of a high degree of agreement and reliability, as all had an intraclass correlation coefficient above 0.75. The overall intraclass correlation coefficient was 0.89.

CONCLUSION

The translated version of the Critical Care Functional Rehabilitation Outcome Measure scale for assessing the functionality of patients admitted to an intensive care unit can be used reliably in Brazil following translation and cross-cultural adaptation to Brazilian Portuguese and presents evidence of excellent interrater reliability.

Physical Function in Critically Ill Patients during the Duration of ICU and Hospital Admission

Background

Impaired physical activity and functional ability is a significant problem in critical illness survivors. Measurement of physical functioning through intensive care unit (ICU) stay determines patients at risk of poor physical outcomes, monitors efficacy of intervention, and informs recovery trajectories.

Objectives

Study objective was to assess physical function trajectory and identify residual functional limitations in critically ill patients admitted to ICU at the point of discharge from the hospital using robust clinical measures.

Materials and methods

Following ethical approval, 100 patients (78 males and 22 females) admitted to medical and surgical ICUs were recruited. Scores on Functional Status Score in ICU (FSS-ICU), Physical Function ICU Test (PFIT), and Functional Independence Measure (FIM) were recorded. Day of physiotherapy reference in the ICU was considered as day of ICU admission. Data were collected at three points, namely ICU admission, ICU discharge, and hospital discharge.

Results

Scores on all outcome measures increased linearly, and an upward functional trajectory was observed in patients from the point of ICU admission till hospital discharge (p >0.001).

Conclusion

Deficits in functional recovery exist until hospital discharge, substantiating the need to implement home-based rehabilitation to recover optimum physical function and independence in activities of daily living.

How to cite this article

Aglawe DR, Agarwal BM, Sawant BD. Physical Function in Critically Ill Patients during the Duration of ICU and Hospital Admission. Indian J Crit Care Med 2022;26(3):314–318.

β-Hydroxy-β-methylbutyrate (HMB) supplementation and functional outcomes in multi-trauma patients: a study protocol for a pilot randomised clinical trial (BOOST trial)

Background

There are no therapies proven to diminish the muscle wasting that occurs in patients after major trauma who are admitted to the intensive care unit (ICU). β-Hydroxy-β-methylbutyrate (HMB) is a nutrition intervention that may attenuate muscle loss and, thereby, improve recovery. The primary aim of this study is to determine the feasibility of a blinded randomised clinical trial of HMB supplementation to patients after major trauma who are admitted to the ICU. Secondary aims are to establish estimates for the impact of HMB when compared to placebo on muscle mass and nutrition-related patient outcomes.

Methods

This prospective, single-centre, blinded, randomised, placebo-controlled, parallel-group, feasibility trial with allocation concealment will recruit 50 participants over 18 months. After informed consent, participants will be randomised [1:1] to receive either the intervention (three grams of HMB dissolved in either 150 ml of orange juice for those allowed oral intake or 150 ml of water for those being enterally fed) or placebo (150 ml of orange juice for those allowed oral intake or 150 ml of water for those being enterally fed). The intervention will be commenced in ICU, continued after ICU discharge and ceased at hospital discharge or day 28 post randomisation, whichever occurs first. The primary outcome is the feasibility of administering the intervention. Secondary outcomes include change in muscle thickness using ultrasound and other nutritional and patient-centred outcomes.

Discussion

This study aims to determine the feasibility of administering HMB to critically ill multi-trauma patients throughout ICU admission until hospital discharge. Results will inform design of a larger randomised clinical trial.

Trial registration

The protocol is registered with Australian New Zealand Clinical Trials Registry (ANZCTR) ANZCTR: 12620001305910. UTN: U1111-1259-5534.

Psychometric Properties of the Barthel Index Used at Intensive Care Unit Discharge

BACKGROUND

The Barthel Index, originally developed and validated to assess activities of daily living in patients with neuromuscular disorders, is commonly used in research and clinical practice involving critically ill patients.

OBJECTIVES

To evaluate the internal consistency, reliability, measurement error, and construct validity of the Barthel Index used at intensive care unit discharge.

METHODS

In this observational study, 2 physiotherapists measured the physical functioning of 122 patients at intensive care unit discharge, using the Barthel Index and other measurement instruments.

RESULTS

The patients had a median (IQR) age of 56 (47-66) years, and 62 patients (51%) were male. The primary reason for intensive care unit admission was sepsis (28 patients [23%]), and 83 patients (68%) were receiving mechanical ventilation. The Cronbach α value indicating internal consistency was 0.81. For interrater reliability, the intraclass correlation coefficient for the total score was 0.98 (95% CI, 0.97-0.98; P < .001) and the κ statistic for the individual items was 0.54 to 0.94. The standard error of measurement was 7.22, the smallest detectable change was 20.01, and the 95% limits of agreement were -10.3 and 11.8. The Barthel Index showed moderate to high correlations with the other physical functioning measurement instruments (ρ = 0.57 to 0.88; P < .001 for all).

CONCLUSION

The Barthel Index is a reliable and valid instrument for assessing physical functioning at intensive care unit discharge.

Survey of Physiotherapy Practice in Ontario Cardiac Surgery Intensive Care Units

Purpose: This article describes current physiotherapy practice for critically ill adult patients requiring prolonged stays in critical care (> 3 d) after complicated cardiac surgery in Ontario. Method: We distributed an electronic, self-administered 52-item survey to 35 critical care physiotherapists who treat adult cardiac surgery patients at 11 cardiac surgical sites. Pilot testing and clinical sensibility testing were conducted beforehand. Participants were sent four email reminders. Results: The response rate was 80% (28/35). The median reported number of cardiac surgeries performed per week was 30 (interquartile range [IQR] 10), with a median number of 14.5 (IQR 4) cardiac surgery beds per site. Typical reported caseloads ranged from 6 to 10 patients per day per therapist, and 93% reported that they had initiated physiotherapy with patients once they were clinically stable in the intensive care unit. Of 28 treatments, range of motion exercises (27; 96.4%), airway clearance techniques (26; 92.9%), and sitting at the edge of the bed (25; 89.3%) were the most common. Intra-aortic balloon pump and extracorporeal membrane oxygenation appeared to limit physiotherapy practice. Use of outcome measures was limited. Conclusions: Physiotherapists provide a variety of interventions to critically ill cardiac surgery patients. Further evaluation of the limited use of outcome measures in the cardiac surgical intensive care unit is warranted.

The effect of passive mobilization associated with blood flow restriction and combined with electrical stimulation on cardiorespiratory safety, neuromuscular adaptations, physical function, and quality of life in comatose patients in an ICU: a randomized controlled clinical trial

Background

Intensive care unit-acquired atrophy and weakness are associated with high mortality, a reduction in physical function, and quality of life. Passive mobilization (PM) and neuromuscular electrical stimulation were applied in comatose patients; however, evidence is inconclusive regarding atrophy and weakness prevention. Blood flow restriction (BFR) associated with PM (BFRp) or with electrical stimulation (BFRpE) was able to reduce atrophy and increase muscle mass in spinal cord-injured patients, respectively. Bulky venous return occurs after releasing BFR, which can cause unknown repercussions on the cardiovascular system. Hence, the aim of this study was to investigate the effect of BFRp and BFRpE on cardiovascular safety and applicability, neuromuscular adaptations, physical function, and quality of life in comatose patients in intensive care units (ICUs).

Methods

Thirty-nine patients will be assessed at baseline (T0–18 h of coma) and randomly assigned to the PM (control group), BFRp, or BFRpE groups. The training protocol will be applied in both legs alternately, twice a day with a 4-h interval until coma awake, death, or ICU discharge. Cardiovascular safety and applicability will be evaluated at the first training session (T1). At T0 and 12 h after the last session (T2), muscle thickness and quality will be assessed. Global muscle strength and physical function will be assessed 12 h after T2 and ICU and hospital discharge for those who wake up from coma. Six and 12 months after hospital discharge, physical function and quality of life will be re-assessed.

Discussion

In view of applicability, the data will be used to inform the design and sample size of a prospective trial to clarify the effect of BFRpE on preventing muscle atrophy and weakness and to exert the greatest beneficial effects on physical function and quality of life compared to BFRp in comatose patients in the ICU.

Trial registration

Universal Trial Number (UTN) Registry UTN U1111-1241-4344. Retrospectively registered on 2 October 2019. Brazilian Clinical Trials Registry (ReBec) RBR-2qpyxf. Retrospectively registered on 21 January 2020, http://ensaiosclinicos.gov.br/rg/RBR-2qpyxf/

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05916-z.

Early Rehabilitation Index: translation and cross-cultural adaptation to Brazilian Portuguese; and Early Rehabilitation Barthel Index: validation for use in the intensive care unit

Objetivo

Traduzir, adaptar transculturalmente para o português do Brasil o instrumento Early Rehabilitation Index e validar para uso na unidade de terapia intensiva o instrumento Early Rehabilitation Barthel Index, para avaliação do estado funcional.

Métodos

Foram executadas as seguintes etapas: preparação, tradução, reconciliação, tradução reversa, revisão, harmonização, pré-teste e avaliação psicométrica. Após esse processo inicial, a versão em português foi aplicada por dois avaliadores em pacientes que permaneciam pelo menos 48 horas internados na unidade de terapia intensiva. Verificou-se a confiabilidade da escala por meio da consistência interna, da confiabilidade entre avaliadores e do efeito piso e teto. Para a validade de constructo, correlacionou-se o Early Rehabilitation Barthel Index com instrumentos que usualmente são utilizados para avaliação do estado funcional na unidade de terapia intensiva.

Resultados

Participaram 122 pacientes com mediana de idade de 56 [46,8 - 66] anos. O Early Rehabilitation Barthel Index teve confiabilidade adequada com coeficiente alfa de Cronbach de 0,65. A confiabilidade entre avaliadores foi excelente, com coeficiente de correlação intraclasse de 0,94 (IC95% 0,92 - 0,96) e moderado a excelente com índice de concordância de kappa de 0,54 a 1,0. Os efeitos piso e teto foram mínimos. Observou-se a validade do Early Rehabilitation Barthel Index por meio das correlações com o escore total do Perme Escore (rô = 0,72), da Escala de Estado Funcional em UTI (rô = 0,77), do Physical Function in Intensive Care Test-score (rô = 0,69), do Medical Research Council sum score (rô = 0,58), além das dinamometrias de preensão palmar (rô = 0,58) e manual de coxa (rô = 0,55), todos com p < 0,001.

Conclusão

A versão adaptada do Early Rehabilitation Index para o português brasileiro e na sua totalidade, Early Rehabilitation Barthel Index é confiável e válida para avaliação do estado funcional dos pacientes na alta da unidade de terapia intensiva.

Physical activity of patients with critical illness undergoing rehabilitation in intensive care and on the acute ward: An observational cohort study

BACKGROUND

There are limited published data on physical activity of survivors of critical illness engaged in rehabilitation in hospital, despite it plausibly influencing outcome.

OBJECTIVE

The aims of this study were to measure physical activity of patients with critical illness engaged in rehabilitation in the intensive care unit (ICU) and on the acute ward and report discharge destination, muscle strength, and functional outcomes.

METHODS

This was a single-centre, prospective observational study. Adults with critical illness, who received ≥48 h of invasive mechanical ventilation, and who were awake and able to participate in rehabilitation were eligible. To record physical activity, participants wore BodyMedia SenseWear Armbands (BodyMedia Incorporated, USA), during daylight hours, from enrolment until hospital discharge or day 14 of ward stay (whichever occurred first). The primary outcome was time (minutes) spent performing physical activity at an intensity of greater than 1.5 Metabolic Equivalent Tasks. Secondary outcomes included discharge destination, muscle strength, and physical function.

RESULTS

We collected 807 days of physical activity data (363 days ICU, 424 days ward) from 59 participants. Mean (standard deviation) duration of daily physical activity increased from the ICU, 17.8 (22.8) minutes, to the ward, 52.8 (51.2) minutes (mean difference [95% confidence interval] = 35 [23.8-46.1] minutes, P < .001). High levels of activity in the ICU were associated with higher levels of activity on the ward (r = .728), n = 48, P < .001.

CONCLUSIONS

Patients recovering from critical illness spend less than 5% of the day being physically active throughout hospital admission, even when receiving rehabilitation. Physical activity increased after discharge from intensive care, but had no relationship with discharge destination. Only the absence of ICU-acquired weakness on awakening was associated with discharge directly home from the acute hospital. Future studies could target early identification of ICU-acquired weakness and the preservation of muscle strength to improve discharge outcomes.

Functional electrical stimulation-assisted cycle ergometry-based progressive mobility programme for mechanically ventilated patients: randomised controlled trial with 6 months follow-up

PURPOSE

Functional electrical stimulation-assisted cycle ergometry (FESCE) enables in-bed leg exercise independently of patients' volition. We hypothesised that early use of FESCE-based progressive mobility programme improves physical function in survivors of critical care after 6 months.

METHODS

We enrolled mechanically ventilated adults estimated to need >7 days of intensive care unit (ICU) stay into an assessor-blinded single centre randomised controlled trial to receive either FESCE-based protocolised or standard rehabilitation that continued up to day 28 or ICU discharge.

RESULTS

We randomised in 1:1 ratio 150 patients (age 61±15 years, Acute Physiology and Chronic Health Evaluation II 21±7) at a median of 21 (IQR 19-43) hours after admission to ICU. Mean rehabilitation duration of rehabilitation delivered to intervention versus control group was 82 (IQR 66-97) versus 53 (IQR 50-57) min per treatment day, p<0.001. At 6 months 42 (56%) and 46 (61%) patients in interventional and control groups, respectively, were alive and available to follow-up (81.5% of prespecified sample size). Their Physical Component Summary of SF-36 (primary outcome) was not different at 6 months (50 (IQR 21-69) vs 49 (IQR 26-77); p=0.26). At ICU discharge, there were no differences in the ICU length of stay, functional performance, rectus femoris cross-sectional diameter or muscle power despite the daily nitrogen balance was being 0.6 (95% CI 0.2 to 1.0; p=0.004) gN/m2 less negative in the intervention group.

CONCLUSION

Early delivery of FESCE-based protocolised rehabilitation to ICU patients does not improve physical functioning at 6 months in survivors.

TRIAL REGISTRATION NUMBER

NCT02864745.

Post-intensive Care Syndrome

The increasing survival rate after discharge from the intensive care unit (ICU) has revealed long-term impairments in the cognitive, psychiatric, and physical domains among survivors. However, clinicians often fail to recognize this post-ICU syndrome (PICS) and its debilitating effects on family members (PICS-F). This study describes two cases of PICS to illustrate the different impairments that may occur in ICU survivors. The PICS risk factors for each domain and the interactions among risk factors are also described. In terms of diagnostic evaluation, limited evidence-based or validated tools are available to assist with screening for PICS. Clinicians should be aware to monitor for its symptoms on the basis of cognitive, psychiatric, and physical domains. The Montreal Cognitive Assessment is recommended to screen for cognition, as it has a high sensitivity and can evaluate executive function. Mood disorders should also be screened. For mobile patients, a 6-minute walk test should be performed. PICS can be prevented by applying the ABCDEF bundle ABCDEF bundle in ICU described in this paper. Finally, the family members of patients in the ICU should be involved in patient care and a tactful communication approach is required to reduce the risk of PICS-F.

Evaluating Physical Functioning in Survivors of Critical Illness: Development of a New Continuum Measure for Acute Care

OBJECTIVES

Evaluation of physical functioning is central to patient recovery from critical illness-it may enable the ability to determine recovery trajectories, evaluate rehabilitation efficacy, and predict individuals at highest risk of ongoing disability. The Physical Function in ICU Test-scored is one of four recommended physical functioning tools for use within the ICU; however, its utility outside the ICU is poorly understood. The De Morton Mobility Index is a common geriatric mobility tool, which has had limited evaluation in the ICU population. For the field to be able to track physical functioning recovery, we need a measurement tool that can be used in the ICU and post-ICU setting to accurately measure physical recovery. Therefore, this study sought to: 1) examine the clinimetric properties of two measures (Physical Function in ICU Test-scored and De Morton Mobility Index) and 2) transform these measures into a single measure for use across the acute care continuum.

DESIGN

Clinimetric analysis.

SETTING

Multicenter study across four hospitals in three countries (Australia, Singapore, and Brazil).

PATIENTS

One hundred fifty-one ICU patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Physical function tests (Physical Function in ICU Test-scored and De Morton Mobility Index) were assessed at ICU awakening, ICU, and hospital discharge. A significant floor effect was observed for the De Morton Mobility Index at awakening (23%) and minimal ceiling effects across all time points (5-12%). Minimal floor effects were observed for the Physical Function in ICU Test-scored across all time points (1-7%) and a significant ceiling effect for Physical Function in ICU Test-scored at hospital discharge (27%). Both measures had strong concurrent validity, responsiveness, and were predictive of home discharge. A new measure was developed using Rasch analytical principles, which involves 10 items (scored out of 19) with minimal floor/ceiling effects.

CONCLUSIONS

Limitations exist for Physical Function in ICU Test-scored and De Morton Mobility Index when used in isolation. A new single measure was developed for use across the acute care continuum.

The Perme Mobility Index: A new concept to assess mobility level in patients with coronavirus (COVID-19) infection

Introduction

The Coronavirus Disease 2019 (COVID-19) outbreak is evolving rapidly worldwide. Data on the mobility level of patients with COVID-19 in the intensive care unit (ICU) are needed.

Objective

To describe the mobility level of patients with COVID-19 admitted to the ICU and to address factors associated with mobility level at the time of ICU discharge.

Methods

Single center, retrospective cohort study. Consecutive patients admitted to the ICU with confirmed COVID-19 infection were analyzed. The mobility status was assessed by the Perme Score at admission and discharge from ICU with higher scores indicating higher mobility level. The Perme Mobility Index (PMI) was calculated [PMI = ΔPerme Score (ICU discharge–ICU admission)/ICU length of stay]. Based on the PMI, patients were divided into two groups: “Improved” (PMI > 0) and “Not improved” (PMI ≤ 0).

Results

A total of 136 patients were included in this analysis. The hospital mortality rate was 16.2%. The Perme Score improved significantly when comparing ICU discharge with ICU admission [20.0 (7–28) points versus 7.0 (0–16) points; P < 0.001]. A total of 88 patients (64.7%) improved their mobility level during ICU stay, and the median PMI of these patients was 1.5 (0.6–3.4). Patients in the improved group had a lower duration of mechanical ventilation [10 (5–14) days versus 15 (8–24) days; P = 0.021], lower hospital length of stay [25 (12–37) days versus 30 (11–48) days; P < 0.001], and lower ICU and hospital mortality rate. Independent predictors for mobility level were lower age, lower Charlson Comorbidity Index, and not having received renal replacement therapy.

Conclusion

Patients’ mobility level was low at ICU admission; however, most patients improved their mobility level during ICU stay. Risk factors associated with the mobility level were age, comorbidities, and use of renal replacement therapy.

German version of the Chelsea Critical Care Physical Assessment Tool (CPAx-GE): translation, cross-cultural adaptation, validity, and reliability

PURPOSE

To translate and cross-culturally adapt the Chelsea Critical Care Physical Assessment tool from English to German (CPAx-GE) and to examine its validity and reliability.

MATERIALS AND METHODS

Following a forward-backward translation including an expert round table discussion, the measurement properties of the CPAx-GE were explored in critically ill, mechanically ventilated adults. We investigated construct, cross-sectional, and cross-cultural validity of the CPAx-GE with other measurement instruments at pre-specified timepoints, analysed relative reliability with intraclass correlation coefficients (ICCs) and determined absolute agreement with the Bland-Altman plots.

RESULTS

Consensus for the translated CPAx-GE was reached. Validity was excellent with >80% of the pre-specified hypotheses accepted at baseline, critical care, and hospital discharge. Interrater reliability was high (ICCs > 0.8) across all visits. Limit of agreement ranged from -2 to 2 points. Error of measurement was small, floor, and ceiling effects limited.

CONCLUSIONS

The CPAx-GE demonstrated excellent construct, cross-sectional, and cross-cultural validity as well as high interrater reliability in critically ill adults with prolonged mechanical ventilation at baseline, critical care, and hospital discharge. Consequently, the CPAx-GE can be assumed equal to the original and recommended in the German-speaking area to assess physical function and activity of critically ill adults across the critical care and hospital stay. Trial registration: German Clinical Trials Register (DRKS) identification number: DRKS00012983 (https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00012983), registered on 20 September 2017, first patient enrolled on 21 November 2017.Implications for rehabilitationEarly rehabilitation of critically ill patients is recommended to prevent and treat the subsequent functional disability, but a suitable measurement instrument for the German-speaking area is lacking.The translated, cross-culturally adapted German CPAx demonstrated excellent validity and reliability in assessing physical function and activity in critically ill adults.Cross-sectional validity of the CPAx has been newly established and allows the use of this tool at clinically relevant time-points in the course of a critical illness.The CPAx-GE can therefore be used in clinical practice by German-speaking therapists to assess physical function and activity during early rehabilitation in the ICU and hospital.

The psychometric properties and minimal clinically important difference for disability assessment using WHODAS 2.0 in critically ill patients

Objectives: The 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) provides a standardised method for measuring health and disability. This study aimed to determine its reliability, validity and responsiveness and to establish the minimum clinically important difference (MCID) in critically ill patients. Design: Prospective, multicentre cohort study. Setting: Intensive care units of six metropolitan hospitals. Participants: Adults mechanically ventilated for > 24 hours. Main outcome measures: Reliability was assessed by measuring internal consistency. Construct validity was assessed by comparing WHODAS 2.0 scores at 6 months with the EuroQoL visual analogue scale (EQ VAS) and Lawton Instrumental Activities of Daily Living (IADL) scale scores. Responsiveness was evaluated by assessing change over time, effect sizes, and percentage of patients showing no change. The MCID was calculated using both anchor and distribution-based methods with triangulation of results. Main results: A baseline and 6-month WHODAS 2.0 score were available for 448 patients. The WHODAS 2.0 demonstrated good correlation between items with no evidence of item redundancy. Cronbach α coefficient was 0.91 and average split-half coefficient was 0.91. There was a moderate correlation between the WHODAS 2.0 and the EQ VAS scores (r = -0.72; P < 0.001) and between the WHODAS 2.0 and the Lawton IADL scores (r = -0.66; P < 0.001) at 6 months. The effect sizes for change in the WHODAS 2.0 score from baseline to 3 months and from 3 to 6 months were low. Ceiling effects were not present and floor effects were present at baseline only. The final MCID estimate was 10%. Conclusion: The 12-item WHODAS 2.0 is a reliable, valid and responsive measure of disability in critically ill patients. A change in the total WHODAS 2.0 score of 10% represents the MCID.

Early rehabilitation after lung transplantation with extracorporeal membrane oxygenation (ECMO) of COVID-19 patient: a case report

Even when severe acute respiratory syndrome coronavirus 2-related coronavirus disease 2019 (COVID-19) is treated with first-line drugs, it progresses and leads to irreversible loss of lung function in some critically ill patients, and lung transplantation is an effective treatment for end-stage chronic pulmonary disease. This case report mainly describes the rehabilitation of a 66-year-old female patient with severe COVID-19 after bilateral lung transplantation. The old patient had a body mass index of 31.2 kg/m². She underwent bilateral lung transplantation due to severe and irreversible injury of both lungs. Long-term mechanical ventilation and extracorporeal membrane oxygenation (ECMO) treatment and preoperative and postoperative high-dose corticosteroid therapy and due to the size of the donor lung does not match the size of the recipient’s diseased lung, and the right middle lobe of the graft is removed before transplantation. Weaning from the ventilator failed due to weak neuromuscular drive, and muscle strength. A full, personalized pulmonary rehabilitation program was initiated with the help of the physical therapists, the respiratory therapy, the doctors, the nurses and psychotherapist team based on the functional levels. The rehabilitation intervention was conducted on postoperative day 4, This included posture management, airway clearance techniques, respiratory training, muscle strength training, transfer training, daily therapeutic bronchoscopy and psychological support. The ECMO was removed successfully on the fifth day. the patient’s physical function, muscle strength and the quality of life has been improved. The good prognosis after rehabilitation indicates that early rehabilitation intervention is effective and feasible and safety for patients after lung transplantation.

The predictive validity of the Functional Assessment for Burns - Critical Care (FAB-CC) score for discharge outcomes in major burns

INTRODUCTION

Physical function scoring of burn ICU patients is recommended but currently validated scores are lacking.

OBJECTIVE

To evaluate the predictive validity of the FAB -CC for burn ICU patients' discharge outcome.

METHODS

All patients underwent daily exercise and FAB -CC screen if they were stable. Two FAB-CC scores were performed; FAB-CC1 on the first day the patient passed the FAB-CC screen, FAB-CC2 within 48 h before ICU discharge. Hospital discharge outcome was defined as transfer for further inpatient rehabilitation or home with social care versus home with no social care. 76 patients' data were entered into the analyses. We used multiple logistic regression analysis to identify variables that predict discharge outcome.

RESULTS

Increasing patient age (p = 0.001), duration of ventilation (p = 0.0003), ICU Length of stay (LOS) (p = 0.0001), total hospital LOS (p < 0.0001), presence of cardiopulmonary disease (p = 0.008), neurological disorder (p = 0.0003) and psychiatric illness (p = 0.003) are positively associated with transfer for inpatient rehabilitation or home with social care. Increasing FAB-CC1 (p < 0.0001) and FAB -CC2 (p = 0.0001) are negatively associated with transfer for inpatient rehabilitation or home with social care. The most predictive model for discharge outcome combined the variables patient age, FAB-CC1, FAB-CC2 and psychiatric illness. Patient age (p = 0.01), FAB-CC1 (p = 0.02) and psychiatric illness (p = 0.009) independently predict discharge outcome.

CONCLUSIONS

FAB-CC2 is associated with, and FAB-CC1 has predictive validity for, patient hospital discharge outcome. These findings, in conjunction with our earlier work, confirm clinical utility of the FAB-CC for burns ICU patients.

Effectiveness, Safety, and Barriers to Early Mobilization in the Intensive Care Unit

Purpose

Patients admitted to the intensive care unit (ICU) are generally confined to bed leading to limited mobility that may have detrimental effects on different body systems. Early mobilization prevents or reduces these effects and improves outcomes in patients following critical illness. The purpose of this review is to summarize different aspects of early mobilization in intensive care.

Methods

Electronic databases of PubMed, Google Scholar, ScienceDirect, and Scopus were searched using a combination of keywords. Full-text articles meeting the inclusion criteria were selected.

Results

Fifty-six studies on various aspects such as the effectiveness of early mobilization in various intensive care units, newer techniques in early mobilization, outcome measures for physical function in the intensive care unit, safety, and practice and barriers to early mobilization were included. Conclusion: Early mobilization is found to have positive effects on various outcomes in patients with or without mechanical ventilation. The newer techniques can be used to facilitate early mobilization. Scoring systems—specific to the ICU—are available and should be used to quantify patients' status at different intervals of time. Early mobilization is not commonly practiced in many countries. Various barriers to early mobilization have been identified, and different strategies can be used to overcome them.

Effectiveness of structured early mobilization protocol on mobility status of patients in medical intensive care unit

INTRODUCTION

Patients admitted to the intensive care units (ICU) have limited mobility due to their illness and its management and are at a risk for immobility-related complications. Early mobilization has been suggested to prevent or limit physical dysfunction due to these complications. Effectiveness of early mobilization protocols is studied using various outcomes.

OBJECTIVE

To study the effectiveness of an early mobilization protocol on mobility status of patients in Medical ICU.

METHODS

Patients admitted to Medical ICU were screened for eligibility and allotted into two groups. Intervention group received mobilization according to a protocol while control group received mobilization as per usual mobilization practices in our ICU. Mobility was assessed using the Perme ICU mobility score on the first day of ICU, first day of rehabilitation and last day of rehabilitation.

RESULTS

63 patients were included in the study. The median difference in the Perme ICU mobility score from first day of rehabilitation to last day of rehabilitation was 9 and 2 in the intervention group and control group respectively. Significant improvements in the mobility scores were not present from first day of ICU to first day of rehabilitation in both, the intervention (p = .069) and control group (p = .124). Improvement in the scores from first day of rehabilitation to last day of rehabilitation was significant within and between both the groups (p < .001).

CONCLUSION

Early Mobilization Protocol was effective in improving mobility status of patients in Medical ICU.

Quadriceps strength in intensive care unit survivors: Variability and influence of preadmission physical activity

BACKGROUND

Muscle weakness is common in patients who survive a stay in the intensive care unit (ICU). Quadriceps strength (QS) measurement allows evaluation of lower limb performances that are associated with mobility outcomes.

OBJECTIVES

The objective of the study was to characterise the range of QS in ICU survivors (ICUS) during their short-term evolution, by comparing them with surgical patients without critical illness and with healthy participants. The secondary aim was to explore whether physical activity before ICU admission influenced QS during that trajectory.

METHODS

Patients with length of ICU stay ≥2 days, adults scheduled for elective colorectal surgery, and young healthy volunteers were included. Maximal isometric QS was assessed using a handheld dynamometer and a previously validated standardised protocol. The dominant leg was tested in the supine position. ICUSs were tested in the ICU and 1 month after ICU discharge, while surgical patients were tested before and on the day after surgery, as well as 1 month after discharge. Healthy patients were tested once only. Patients were classified as physically inactive or active before admission from the self-report.

RESULTS

Thirty-eight, 32, and 34 participants were included in the ICU, surgical, and healthy groups, respectively. Demographic data were similar in the ICUS and surgical groups. In the ICU, QS was lower in the ICU group than in the surgical and healthy groups (3.01 [1.88-3.48], 3.38 [2.84-4.37], and 5.5 [4.75-6.05] N/kg, respectively). QS did not significantly improve 1 month after ICU discharge, excepted in survivors who were previously physically active (22/38, 56%): the difference between the two time points was -6.6 [-27.1 to -1.7]% vs 20.4 [-3.4 to 43.3]%, respectively, in physically inactive and active patients (p = 0.002).

CONCLUSIONS

Patients who survived an ICU stay were weaker than surgical patients. However, a huge QS heterogeneity was observed among them. Their QS did not improve during the month after ICU discharge. Physically inactive patients should be early identified as at risk of poorer recovery.

Geriatric Rehabilitation and COVID-19: a Case Report

The COVID-19 infection has particularly affected older adults. Clinical observations in this population highlight major respiratory impairment associated with the development or aggravation of the patient’s frailty state. Mr. P is a 93-year-old frail patient, hospitalized after a COVID-19 infection. The assessment process of this patient has been supported by an innovative multi-systemic tool developed in view of the COVID-19 clinical consequences and a systemic evaluation of motor functions by the Frail’BESTest. This process allowed a mixed clinical picture associated with significant respiratory distress (linked with acute respiratory distress syndrome) and an evident motor frailty. The care plan was developed accordingly, and four assessments were done in the same manner until Mr. P returned home. This case report allows us to see a holistic COVID-19 clinical picture, showing the different axes of clinical reasoning to enhance the rehabilitation process. Furthermore, this case report illustrates the importance of rehabilitation in the COVID-19 context.

Physical Therapist Management of COVID-19 in the Intensive Care Unit: The West China Hospital Experience

OBJECTIVE

Coronavirus disease 2019 (COVID-19) has dominated the attention of health care systems globally since January 2020. Various health disciplines, including physical therapists, are still exploring the best way to manage this new disease. The role and involvement of physical therapists in the management of COVID-19 are not yet well defined and are limited in many hospitals. This article reports a physical therapy service specially commissioned by the Health Commission of Sichuan Province to manage COVID-19 during patients' stay in the intensive care unit (ICU) at the Public Health Clinical Center of Chengdu in China.

METHODS

Patients diagnosed with COVID-19 were classified into 4 categories under a directive from the National Health Commission of the People's Republic of China. Patients in the "severe" and "critical" categories were admitted to the ICU irrespective of mechanical ventilation was required. Between January 31, 2020, and March 8, 2020, a cohort of 16 patients was admitted to the ICU at the Public Health Clinical Center of Chengdu. The median (minimum to maximum) hospital and ICU stays for these patients were 27 (11-46) and 15 (6-38) days, respectively. Medical management included antiviral, immunoregulation, and supportive treatment of associated comorbidities. Physical therapist interventions included body positioning, airway clearance techniques, oscillatory positive end-expiratory pressure, inspiratory muscle training, and mobility exercises. All patients had at least 1 comorbidity. Three of the 16 patients required mechanical ventilation and were excluded for outcome measures that required understanding of verbal instructions. In the remaining 13 patients, respiratory outcomes-including the Borg Dyspnea Scale, peak expiratory flow rate, Pao2/Fio2 ratio, maximal inspiratory pressure, strength outcomes, Medical Research Council Sum Score, and functional outcomes (including the Physical Function in Intensive Care Test score, De Morton Mobility Index, and Modified Barthel Index)-were measured on the first day the patient received the physical therapist intervention and at discharge.

RESULTS

At discharge from the ICU, while most outcome measures were near normal for the majority of the patients, 61% and 31% of these patients had peak expiratory flow rate and maximal inspiratory pressure, respectively, below 80% of the predicted value and 46% had De Morton Mobility Index values below the normative value.

CONCLUSION

The respiratory and physical functions of some patients remained poor at ICU discharge, suggesting that long-term rehabilitation may be required for these patients.

IMPACT

Our experience in the management of patients with COVID-19 has revealed that physical therapist intervention is safe and appears to be associated with an improvement in respiratory and physical function in patients with COVID-19 in the ICU.

Acute skeletal muscle wasting and dysfunction predict physical disability at hospital discharge in patients with critical illness

BACKGROUND

Patients surviving critical illness develop muscle weakness and impairments in physical function; however, the relationship between early skeletal muscle alterations and physical function at hospital discharge remains unclear. The primary purpose of this study was to determine whether changes in muscle size, strength and power assessed in the intensive care unit (ICU) predict physical function at hospital discharge.

METHODS

Study design is a single-center, prospective, observational study in patients admitted to the medicine or cardiothoracic ICU with diagnosis of sepsis or acute respiratory failure. Rectus femoris (RF) and tibialis anterior (TA) muscle ultrasound images were obtained day one of ICU admission, repeated serially and assessed for muscle cross-sectional area (CSA), layer thickness (mT) and echointensity (EI). Muscle strength, as measured by Medical Research Council-sum score, and muscle power (lower-extremity leg press) were assessed prior to ICU discharge. Physical function was assessed with performance on 5-times sit-to-stand (5STS) at hospital discharge.

RESULTS

Forty-one patients with median age of 61 years (IQR 55-68), 56% male and sequential organ failure assessment score of 8.1 ± 4.8 were enrolled. RF muscle CSA decreased significantly a median percent change of 18.5% from day 1 to 7 (F = 26.6, p = 0.0253). RF EI increased at a mean percent change of 10.5 ± 21% in the first 7 days (F = 3.28, p = 0.081). At hospital discharge 25.7% of patients (9/35) met criteria for ICU-acquired weakness. Change in RF EI in first 7 days of ICU admission and muscle power measured prior to ICU were strong predictors of ICU-AW at hospital discharge (AUC = 0.912). Muscle power at ICU discharge, age and ICU length of stay were predictive of performance on 5STS at hospital discharge.

CONCLUSION

ICU-assessed muscle alterations, specifically RF EI and muscle power, are predictors of diagnosis of ICU-AW and physical function assessed by 5x-STS at hospital discharge in patients surviving critical illness.