The physical function intensive care test: implementation in survivors of critical illness

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.

Instruments to assess post-intensive care syndrome assessment: a scoping review and modified Delphi method study

BACKGROUND

The assessment of post-intensive care syndrome (PICS) is challenging due to the numerous types of instruments. We herein attempted to identify and propose recommendations for instruments to assess PICS in intensive care unit (ICU) survivors.

METHODS

We conducted a scoping review to identify PICS follow-up studies at and after hospital discharge between 2014 and 2022. Assessment instruments used more than two times were included in the modified Delphi consensus process. A modified Delphi meeting was conducted three times by the PICS committee of the Japanese Society of Intensive Care Medicine, and each score was rated as not important (score: 1-3), important, but not critical (4-6), and critical (7-9). We included instruments with ≥ 70% of respondents rating critical and ≤ 15% of respondents rating not important.

RESULTS

In total, 6972 records were identified in this scoping review, and 754 studies were included in the analysis. After data extraction, 107 PICS assessment instruments were identified. The modified Delphi meeting reached 20 PICS assessment instrument recommendations: (1) in the physical domain: the 6-min walk test, MRC score, and grip strength, (2) in cognition: MoCA, MMSE, and SMQ, (3) in mental health: HADS, IES-R, and PHQ-9, (4) in the activities of daily living: the Barthel Index, IADL, and FIM, (5) in quality of life: SF-36, SF-12, EQ-5D-5L, 3L, and VAS (6), in sleep and pain: PSQI and Brief Pain Inventory, respectively, and (7) in the PICS-family domain: SF-36, HADS, and IES-R.

CONCLUSION

Based on a scoping review and the modified Delphi method, 20 PICS assessment instruments are recommended to assess physical, cognitive, mental health, activities of daily living, quality of life, sleep, and pain in ICU survivors and their families.

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).

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.

Early Neuromuscular Electrical Stimulation in Addition to Early Mobilization Improves Functional Status and Decreases Hospitalization Days of Critically Ill Patients

OBJECTIVES

To evaluate the impact of the additional use of early neuromuscular electrical stimulation (NMES) on an early mobilization (EM) protocol.

DESIGN

Randomized controlled trial.

SETTING

ICU of the Clinical Hospital of Ribeirão Preto, University of São Paulo, Brazil.

PATIENTS

One hundred and thirty-nine consecutive mechanically ventilated patients were included in the first 48 hours of ICU admission.

INTERVENTIONS

The patients were divided into two groups: EM and EM+NMES. Both groups received EM daily. In the EM+NMES group, patients additionally received NMES 5 days a week, for 60 minutes, starting in the first 48 hours of ICU admission until ICU discharge.

MEASUREMENTS AND MAIN RESULTS

Functional status, muscle strength, ICU and hospital length of stay (LOS), frequency of delirium, days on mechanical ventilation, mortality, and quality of life were assessed. Patients in the EM+NMES group presented a significant higher score of functional status measured by the Functional Status Score for the ICU scale when compared with the EM group in the first day awake: 22 (15-26) versus 12 (8-22) (p = 0.019); at ICU discharge: 28 (21-33) versus 18 (11-26) (p = 0.004); and hospital discharge: 33 (27-35) versus 25 (17-33) (p = 0.014), respectively. They also had better functional status measured by the Physical Function Test in the ICU scale, took less days to stand up during the ICU stay, and had a significant shorter hospital LOS, lower frequency of ICU-acquired weakness, and better global muscle strength.

CONCLUSIONS

The additional application of early NMES promoted better functional status outcomes on the first day awake and at ICU and hospital discharge. The patients in the EM+NMES group also took fewer days to stand up and had shorter hospital LOS, lower frequency of ICU-acquired weakness, and better muscle strength. Future studies are still necessary to clarify the effects of therapies associated with EM, especially to assess long-term 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.

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.

Chinesisation, adaptation and validation of the Chelsea Critical Care Physical Assessment Tool in critically ill patients: a cross-sectional observational study

PURPOSE

To translate and adapt the Chelsea Critical Care Physical Assessment Tool (CPAx) into Chinese version ('CPAx-Chi'), test the reliability and validity of CPAx-Chi, and verify the cut-off point for the diagnosis of intensive care unit-acquired weakness (ICU-AW).

STUDY DESIGN

Cross-sectional observational study.

METHODS

Forward and back translation, cross-cultural adaptation and pretesting of CPAx into CPAx-Chi were based on the Brislin model. Participants were recruited from the general ICU of five third-grade class-A hospitals in western China. Two hundred critically ill adult patients (median age: 53 years; 64% men) with duration of ICU stay ≥48 hours and Glasgow Coma Scale ≥11 were included in this study. Two researchers simultaneously and independently assessed eligible patients using the Medical Research Council Muscle Score (MRC-Score) and CPAx-Chi.

RESULTS

The content validity index of items was 0.889. The content validity index of scale was 0.955. Taking the MRC-Score scale as standard, the criterion validity of CPAx-Chi was r=0.758 (p<0.001) for researcher A, and r=0.65 (p<0.001) for researcher B. Cronbach's α was 0.939. The inter-rater reliability was 0.902 (p<0.001). The area under the receiver operating characteristic curves of CPAx-Chi for diagnosing ICU-AW based on MRC-Score ≤48 were 0.899 (95% CI 0.862 to 1.025) and 0.874 (95% CI 0.824 to 0.925) for researcher B. The best cut-off point for CPAx-Chi for the diagnosis of ICU-AW was 31.5. The sensitivity was 87% and specificity was 77% for researcher A, whereas it was 0.621, 31.5, 75% and 87% for researcher B, respectively. The consistency was high when taking CPAx-Chi ≤31 and MRC-Score ≤48 as the cut-off points for the diagnosis of ICU-AW. Cohen's kappa=0.845 (p=0.02) in researcher A and 0.839 (p=0.04) for researcher B.

CONCLUSIONS

CPAx-Chi demonstrated content validity, criterion-related validity and reliability. CPAx-Chi showed the best accuracy in assessment of patients at risk of ICU-AW with good sensitivity and specificity at a recommended cut-off of 31.

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.

Implications for post critical illness trial design: sub-phenotyping trajectories of functional recovery among sepsis survivors

BACKGROUND

Patients who survive critical illness suffer from a significant physical disability. The impact of rehabilitation strategies on health-related quality of life is inconsistent, with population heterogeneity cited as one potential confounder. This secondary analysis aimed to (1) examine trajectories of functional recovery in critically ill patients to delineate sub-phenotypes and (2) to assess differences between these cohorts in both clinical characteristics and clinimetric properties of physical function assessment tools.

METHODS

Two hundred ninety-one adult sepsis survivors were followed-up for 24 months by telephone interviews. Physical function was assessed using the Physical Component Score (PCS) of the Short Form-36 Questionnaire (SF-36) and Activities of Daily Living and the Extra Short Musculoskeletal Function Assessment (XSFMA-F/B). Longitudinal trajectories were clustered by factor analysis. Logistical regression analyses were applied to patient characteristics potentially determining cluster allocation. Responsiveness, floor and ceiling effects and concurrent validity were assessed within clusters.

RESULTS

One hundred fifty-nine patients completed 24 months of follow-up, presenting overall low PCS scores. Two distinct sub-cohorts were identified, exhibiting complete recovery or persistent impairment. A third sub-cohort could not be classified into either trajectory. Age, education level and number of co-morbidities were independent determinants of poor recovery (AUROC 0.743 ((95%CI 0.659-0.826), p < 0.001). Those with complete recovery trajectories demonstrated high levels of ceiling effects in physical function (PF) (15%), role physical (RP) (45%) and body pain (BP) (57%) domains of the SF-36. Those with persistent impairment demonstrated high levels of floor effects in the same domains: PF (21%), RP (71%) and BP (12%). The PF domain demonstrated high responsiveness between ICU discharge and at 6 months and was predictive of a persistent impairment trajectory (AUROC 0.859 (95%CI 0.804-0.914), p < 0.001).

CONCLUSIONS

Within sepsis survivors, two distinct recovery trajectories of physical recovery were demonstrated. Older patients with more co-morbidities and lower educational achievements were more likely to have a persistent physical impairment trajectory. In regard to trajectory prediction, the PF score of the SF-36 was more responsive than the PCS and could be considered for primary outcomes. Future trials should consider adaptive trial designs that can deal with non-responders or sub-cohort specific outcome measures more effectively.

Effect of Early Mobilization on Respiratory and Limb Muscle Strength and Functionality of Nonintubated Patients in Critical Care: A Feasibility Trial

Purpose. To assess the potential effectiveness or efficacy of early mobilization on respiratory and peripheral muscle strengths and functionality in nonintubated patients. Methods. For 40 nonintubated patients over 18 years of age with over 24-hour intensive care unit (ICU) stay allocated to a single intervention, an incremental mobilization protocol was initiated. Maximal inspiratory and expiratory pressures (MIP and MEP), peripheral muscle strength (handgrip strength (HGS) and Medical Research Council scale (MRC-s)), and functionality (FIM, ICF-BMS, PFIT-s, and FSS-ICU scales) were evaluated at ICU admission and discharge. Results. All outcomes were significantly improved (pre vs. post values): MIP (43.93 ± 21.95 vs. 54.12 ± 21.68 cmH2O; P<0.001), MEP (50.32 ± 28.65 vs. 60.30 ± 21.23; P=0.002), HGS (25.5 (9.58) vs. 27.5 (9.48); P=0.046), MRC-s (58.52 ± 2.84 vs. 59.47 ± 1.81; P=0.023), FIM (54.4 ± 22.79 vs. 69.48 ± 12.74), ICF-BMS (28.63 ± 16.19 vs. 14.03 ± 11.15), PFIT-s (9.55 ± 2.34 vs. 11.18 ± 1.32) (P<0.001), and FSS-ICU (28.7 ± 9.1 vs. 32.6 ± 5.0; P=0.001). The ceiling effect at admission/discharge was in MRC-s (60/82.5%), FSS-ICU (50/70%), and FIM (35/62.5%). The floor effect occurred at discharge in ICF-BMS (7.5/52.5%). Conclusions. The early mobilization protocol seemed effective at maintaining/increasing the respiratory muscle strength and functionality of nonintubated patients in critical care. Ceiling effect was high for MRC-s, FSS-ICU, and FIM scales.

Analysis of functional status and muscle strength in adults and older adults in an intensive care unit: a prospective cohort study

The aim of this study was to analyze and assess the association between functional status (FS) and muscle strength (MS) in young adults, adults and older adults in an intensive care unit (ICU). We conducted a prospective cohort study with 48 patients. FS was assessed using the Functional Status Score for the Intensive Care Unit (FSS-ICU) and MS was measured using the Medical Research Council Sum-Score (MRC-SS) and by testing handgrip strength (HS). The assessments were performed on awakening and ICU discharge. The data were analyzed using the Kruskall-Wallis, chi-squared, Wilcoxon and Spearman's correlation tests. FS and MRC-SS scores were higher on ICU discharge in all groups. Gains were lowest in the older adult group. HS was greater in both hands on ICU discharge in all groups except the adults. FSS-ICU on both awakening and ICU discharge was highest in the adults; HS-R was lowest in the older adults. There was a strong association between FS and MS in the young adults and adults. FS and MS showed progressive improvement during ICU stay. Gains in FS and MS on awakening and ICU discharge were lowest among the older adults. Important associations were found between these variables in all groups except the older adults. This can be explained by the multifactorial nature of illness and incapacity in this group.

Investigating the interrater reliability of a novel functional outcome measure for use in the burns intensive care unit: The Functional Assessment for Burns - Critical Care (FAB-CC)

INTRODUCTION

Intensive Care Unit Acquired Weakness challenges the clinical care of critically ill patients. Despite a surge in validated ICU functional outcome measures following the publication of Clinical Guideline 83 'Rehabilitation After Critical Illness' by the National Institute for Health and Care Excellence (2009), there are none composed specifically for use in the Burns ICU. We therefore developed and tested the inter-rater reliability of a burn specific novel functional outcome measure; The Functional Assessment for Burns-Critical Care (FAB-CC).

OBJECTIVES

This research aimed to investigate the interrater reliability of the FAB-CC.

METHODS

A quantitative reliability study assessed the ability of the FAB-CC to obtain accurate data when utilised by three separate raters (m=3) scoring the same clinical episodes (n=24).

RESULTS

The Intraclass Correlation Coefficient (ICC) for the FAB-CC as a complete tool revealed excellent agreement (ICC 0.998; P<0.001, 95% confidence interval 0.996-0.999), with Cronbach's Alpha (α 0.999). Individual components of the FAB-CC displayed excellent agreement (ICC>0.983; P<0.001) with narrow 95% confidence intervals.

CONCLUSIONS

The FAB-CC is a novel functional outcome measure that is reliable for use with critically ill burn patients. It has demonstrated real clinical utility in the identification and management of ICU-AW in this unique patient group.

Health-related quality of life, participation, and physical and cognitive function of patients with intensive care unit-acquired muscle weakness 1 year after rehabilitation in Germany: the GymNAST cohort study

OBJECTIVE

To describe predictors for health-related quality of life, participation, physical activity and cognitive function in patients with intensive care unit (ICU)-acquired muscle weakness 1 year after discharge from rehabilitation.

DESIGN

This is a cohort study.

PARTICIPANTS

We included 150 chronic critically ill individuals with ICU-acquired muscle weakness.

SETTING

Postacute ICU and rehabilitation units in Germany.

MEASURES

We measured health-related quality of life using the EQ-5D, participation using the Reintegration of Normal Living Index, physical activity using the Physical Activity Scale for Individuals With Physical Disabilities, and basal cognitive function using the Montreal Cognitive Assessment (MoCA) at 6 months, and the Clock Drawing Test 6 and 12 months after discharge from postacute treatment. We described the predictors of the results at 12 months.

RESULTS

The best predictors for good health-related quality of life 1 year after discharge were the time until regaining walking ability (OR=0.96, OR per day, 95% CI 0.93 to 0.99) and the mean MoCA score on admission to our postacute ICU and rehabilitation units (OR=1.25,95% CI 1.02 to 1.52).The best predictor for good participation 1 year after discharge was the MoCA sum score on admission to our postacute ICU and rehabilitation units (OR=0.85,95% CI 0.72 to 1.00). The best predictor for good physical activity 1 year after discharge was the Apache sum score on admission to our postacute ICU and rehabilitation units (OR=1.68,95% CI 0.89 to 3.13). The best predictor for normal cognitive function 1 year after discharge was regaining walking function in rehabilitation (OR=8.0,95% CI 0.49 to 13.69).

CONCLUSION

Recovery of health-related quality of life, participation, physical activity and basal cognitive function was still not complete 12 months after discharge from postacute treatment. We described the predictors for these important outcomes in participants with ICU-acquired muscle weakness 1 year after discharge from rehabilitation.

TRIAL REGISTRATION NUMBER

DRKS00007181.

A feasibility study of a randomised controlled trial to examine the impact of the ABCDE bundle on quality of life in ICU survivors

Background

Early rehabilitation has been found to prevent delirium and weakness that can hamper the recovery of intensive care unit (ICU) survivors. Integrated clinical practice guidelines for managing patient pain, agitation and delirium (PAD) have been developed. The Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility (ABCDE) bundle provides a strategy to implement PAD guidelines into everyday clinical practice. However, there is limited evidence on the effectiveness of the ABCDE bundle in the literature.

The purpose of this study was to evaluate the feasibility of conducting a full-scale randomised controlled trial comparing the ABCDE bundle to standard care in an ICU. Trial feasibility was defined as the successful recruitment and retention of trial participants, adherence to the intervention, identification of barriers to the intervention, and the rigorous collection of outcome data.

Methods

A prospective, single-centre, randomised controlled feasibility study was conducted. Thirty adult mechanically ventilated participants were recruited from an eight-bed ICU in south east Queensland, Australia, between April 2015 and December 2015. Participants were randomised to receive either the ABCDE bundle or standard routine management. The ABCDE bundle integrated prescribed awakening and breathing trials, delirium monitoring and management, and prescribed exercise and mobility regimes. Feasibility outcomes measured included recruitment and retention rates, intervention fidelity, and the feasibility of participant outcome data collection. Outcome measurement assessors were blinded to participant assignment. It was not possible to blind the research team or the participant to group assignment.

Results

In total, 30 (81.1%) of 37 eligible participants consented and were randomised to the intervention group (n = 15) or the control group (n = 15). Of these, 23 (76.6%) participants successfully completed the 90-day post discharge assessment. A lengthy recruitment period of 8 months was related to overly stringent inclusion and exclusion criteria. Intervention adherence exceeded defined success rates with participation in awakening and breathing trials, delirium monitoring and exercise interventions performed on 80.2, 97.4 and 90.2% of ventilated days respectively. Outcome assessments were successfully and accurately performed at ICU and hospital discharge and 90-day post hospital discharge. Intervention participants were deemed to be delirious on 39.6% of mechanically ventilated days indicating a requirement for a scripted regime to prevent delirium.

Conclusions

With minor adjustment of inclusion and exclusion criteria, the inclusion of delirium management protocols, and encouragement of family engagement and involvement, a large-scale definitive randomised controlled trial to test the impact of the ABCDEF bundle will be feasible.

Trial registration

Australian New Zealand Clinical Trials Registry 12614000763640 Date registered 17/08/2014

Electronic supplementary material

The online version of this article (10.1186/s40814-017-0224-x) contains supplementary material, which is available to authorized users.

Evaluating physical functioning in critical care: considerations for clinical practice and research

The evaluation of physical functioning is valuable in the intensive care unit (ICU) to help inform patient recovery after critical illness, to identify patients who may require rehabilitation interventions, and to monitor responsiveness to such interventions. This viewpoint article discusses: (1) the concept of physical functioning with reference to the World Health Organization International Classification of Functioning, Disability and Health; (2) the importance of measuring physical functioning in the ICU; and (3) methods for evaluating physical functioning in the ICU. Recommendations for clinical practice and research are made, along with discussion of future directions.

Functional Status Score for the ICU: An International Clinimetric Analysis of Validity, Responsiveness, and Minimal Important Difference

OBJECTIVES

To evaluate the internal consistency, validity, responsiveness, and minimal important difference of the Functional Status Score for the ICU, a physical function measure designed for the ICU.

DESIGN

Clinimetric analysis.

SETTINGS

Five international datasets from the United States, Australia, and Brazil.

PATIENTS

Eight hundred nineteen ICU patients.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Clinimetric analyses were initially conducted separately for each data source and time point to examine generalizability of findings, with pooled analyses performed thereafter to increase power of analyses. The Functional Status Score for the ICU demonstrated good to excellent internal consistency. There was good convergent and discriminant validity, with significant and positive correlations (r = 0.30-0.95) between Functional Status Score for the ICU and other physical function measures, and generally weaker correlations with nonphysical measures (|r| = 0.01-0.70). Known group validity was demonstrated by significantly higher Functional Status Score for the ICU scores among patients without ICU-acquired weakness (Medical Research Council sum score, ≥ 48 vs < 48) and with hospital discharge to home (vs healthcare facility). Functional Status Score for the ICU at ICU discharge predicted post-ICU hospital length of stay and discharge location. Responsiveness was supported via increased Functional Status Score for the ICU scores with improvements in muscle strength. Distribution-based methods indicated a minimal important difference of 2.0-5.0.

CONCLUSIONS

The Functional Status Score for the ICU has good internal consistency and is a valid and responsive measure of physical function for ICU patients. The estimated minimal important difference can be used in sample size calculations and in interpreting studies comparing the physical function of groups of ICU patients.

Regaining water swallowing function in the rehabilitation of critically ill patients with intensive-care-unit acquired muscle weakness

PURPOSE

Treatment in intensive care units (ICUs) often results in swallowing dysfunction. Recent longitudinal studies have described the recovery of critically ill people, but we are not aware of studies of the recovery of swallowing function in patients with ICU-acquired muscle weakness. This paper aims to describe the time course of regaining water swallowing function in patients with ICU-acquired weakness in the post-acute phase and to describe the risks of regaining water swallowing function and the risk factors involved.

METHODS

This cohort study included patients with ICU-acquired muscle weakness in our post-acute department, who were unable to swallow. We monitored the process of regaining water swallowing function using the 3-ounce water swallowing test.

RESULTS

We included 108 patients with ICU-acquired muscle weakness. Water swallowing function was regained after a median of 12 days (interquartile range =17) from inclusion in the study and after a median of 59 days (interquartile range= 36) from the onset of the primary illness. Our multivariate Cox Proportional Hazard model yielded two main risk factors for regaining water swallowing function: the number of medical tubes such as catheters at admission to the post-acute department (adjusted hazard ratio [HR] = 1.282; 95% confidence interval [CI]: 1.099-1.495) and the time until weaning from the respirator in days (adjusted HR =1.02 per day; 95%CI: 0.998 to 1.008).

CONCLUSION

We describe a time course for regaining water swallowing function based on daily tests in the post-acute phase of critically ill patients. Risk factors associated with regaining water swallowing function in rehabilitation are the number of medical tubes and the duration of weaning from the respirator. Implications for rehabilitation Little guidance is available for the management of swallowing dysfunction in the rehabilitation of critically ill patients with intensive-care-units acquired muscle weakness. There is a time dependent pattern of recovery from swallowing dysfunction with daily water swallowing tests in the post-acute phase of critically ill patients. Daily water swallowing tests can be used to test swallowing dysfunction in the post-acute phase of critically ill patients The amount of medical tubes and the duration of weaning from respirator are associated risk factors for recovery of swallowing dysfunction.

Implementation of the physical function ICU test tool in a resource constrained intensive care unit to promote early mobilisation of critically ill patients- a feasibility study

Background

The shift of focus in outcome measures from mortality to assessment of functional status in intensive care unit (ICU) patients has resulted in the emergence of mobilisation of critically ill patients as a standard physiotherapy practice in most medium and high income countries. The aim of this study was to determine the feasibility of an early mobilisation program and to report on the changes in patient clinical outcomes following the intervention in a low income country.

Methods

A prospective cohort study was carried out at one public hospital. An adult cohort of 35 patients was recruited within 24 h of being admitted into the unit, irrespective of ventilation method over a period of three months. An early mobilisation programme was implemented and prescribed using the Physical Function ICU Test (PFIT-s) which commenced in either the ICU or high dependent unit.

Results

The median age of the 35 patients was 29 years (IQR = 24–45 years). More than half of the patients had undergone surgery due to either gastrointestinal problems or obstetrical complications. A total of 94 out of a possible of 219 exercise sessions were delivered to the patients (43.0 %). The tool was implemented in 32 (91.4 %) patients on the initial PFIT-s measurement and 16 (45.7 %) of the patients required the assistance of two people to stand. The Initial PFIT-s mean score was 5.3 ± 1.8. On final PFIT-s measurement, out of the 30 (85.7 %) patients seen, 15 (42.9 %) of the patients did not require any assistance to stand and the final PFIT-s mean score was 7.0 ± 1.9. There was a significant difference in both the initial PFIT-s total score (t-value = 2.34, df = 30, p = .03) and the final PFIT-s score (t-value = 3.66, df = 28, p = .001) between males and females. During the treatment, no adverse event occurred in any of the patients.

Conclusion

An early mobilisation program using PFIT-s was feasible and safe. There was a difference in functional capability based on gender, with males being more functionally active. Specific inclusion and exclusion criteria can lead to a delayed early mobilisation activities in ICU patients.

Trial registration

Pan African Clinical Trials Registry PACTR201408000829202. Registered 15 August 2014.

First results about recovery of walking function in patients with intensive care unit-acquired muscle weakness from the General Weakness Syndrome Therapy (GymNAST) cohort study

OBJECTIVES

To describe the time course of recovery of walking function and other activities of daily living in patients with intensive care unit (ICU)-acquired muscle weakness.

DESIGN

This is a cohort study.

PARTICIPANTS

We included critically ill patients with ICU-acquired muscle weakness.

SETTING

Post-acute ICU and rehabilitation units in Germany.

MEASURES

We measured walking function, muscle strength, activities in daily living, motor and cognitive function.

RESULTS

We recruited 150 patients (30% female) who fulfilled our inclusion and exclusion criteria. The primary outcome recovery of walking function was achieved after a median of 28.5 days (IQR=45) after rehabilitation onset and after a median of 81.5 days (IQR=64) after onset of illness. Our final multivariate model for recovery of walking function included two clinical variables from baseline: the Functional Status Score ICU (adjusted HR=1.07 (95% CI 1.03 to 1.12) and the ability to reach forward in cm (adjusted HR=1.02 (95% CI 1.00 to 1.04). All secondary outcomes but not pain improved significantly in the first 8 weeks after study onset.

CONCLUSIONS

We found good recovery of walking function for most patients and described the recovery of walking function of people with ICU-acquired muscle weakness.

TRIALS REGISTRATIONS NUMBER

Sächsische Landesärztekammer EK-BR-32/13-1; DRKS00007181, German Register of Clinical Trials.

Reliability and utility of the Acute Care Index of Function in intensive care patients: An observational study

OBJECTIVES

To establish the inter-rater reliability of the Acute Care Index of Function (ACIF) in intensive care unit (ICU) patients and determine whether ACIF scores have predictive utility beyond ICU discharge.

BACKGROUND

Accurate and reliable measures of physical function are required to describe the recovery trajectory of ICU survivors. The clinimetric properties of the ACIF are yet to be established in ICU patients.

METHODS

Prospective observational study in a single tertiary ICU. ACIF scores were recorded independently by 2 physiotherapists across a convenience sample of 100 physiotherapy assessments, and at ICU discharge.

RESULTS

Inter-rater reliability of total ACIF scores was very strong (ICC = 0.94). ACIF <0.40 at ICU discharge predicted hospital discharge to a destination other than home (area under ROC = 0.79, 95% CI 0.64-0.89) (sensitivity 0.78).

CONCLUSION

The ACIF has excellent inter-rater reliability in ICU patients and scores at ICU discharge predict the likelihood of discharge home.

TRIAL REGISTRATION

ACTRN12614001008617 (September 18 2014).

Combining nutrition and exercise to optimize survival and recovery from critical illness: Conceptual and methodological issues

Survivors of critical illness commonly experience neuromuscular abnormalities, including muscle weakness known as ICU-acquired weakness (ICU-AW). ICU-AW is associated with delayed weaning from mechanical ventilation, extended ICU and hospital stays, more healthcare-related hospital costs, a higher risk of death, and impaired physical functioning and quality of life in the months after ICU admission. These observations speak to the importance of developing new strategies to aid in the physical recovery of acute respiratory failure patients. We posit that to maintain optimal muscle mass, strength and physical function, the combination of nutrition and exercise may have the greatest impact on physical recovery of survivors of critical illness. Randomized trials testing this and related hypotheses are needed. We discussed key methodological issues and proposed a common evaluation framework to stimulate work in this area and standardize our approach to outcome assessments across future studies.

Early mobilization practice in a single Brazilian intensive care unit

OBJECTIVES

To characterize the provision of early mobilization therapy in critically ill patients in a Brazilian medical intensive care unit (ICU) and to investigate the relationship between physical activity level and clinical outcomes.

METHODS

Intensive care unit and physiotherapy data were collected retrospectively from 275 consecutive patients. Here we report on the subset of patients (n = 120) who were mechanically ventilated during their ICU stay (age, 49 ± 18 years; Simplified Acute Physiology Score 3, 45 [25]).

RESULTS

Median (interquartile range) time of mechanical ventilation and ICU length of stay were 3 (4) and 8 (10) days, respectively. Intensive care unit and 1-year mortality were 31% and 50%, respectively. During the ICU stay, these patients all received respiratory physiotherapy and 90% (n = 108) received mobilization therapy. When intubated and ventilated, mobilization therapy was performed in 76% (n = 92) of the patients with no adverse events. The most common activity was in-bed exercises (55%), and the number of out-of-bed activities (sitting out of bed, standing, or walking) was small (29%) and more prevalent in patients with tracheostomy than with an endotracheal tube (27% × 2%, respectively).

CONCLUSION

In our Brazilian ICU, mobilization therapy in critically ill patients was safe and feasible; however, similar to other countries, in-bed exercises were the most prevalent activity. During mechanical ventilation, only a small percentage of activities involved standing or mobilizing away from the bed.

Functional outcomes in ICU – what should we be using? – an observational study

Introduction

With growing awareness of the importance of rehabilitation, new measures are being developed specifically for use in the intensive care unit (ICU). There are currently 26 measures reported to assess function in ICU survivors. The Physical Function in Intensive care Test scored (PFIT-s) has established clinimetric properties. It is unknown how other functional measures perform in comparison to the PFIT-s or which functional measure may be the most clinically applicable for use within the ICU. The aims of this study were to determine (1) the criterion validity of the Functional Status Score for the ICU (FSS-ICU), ICU Mobility Scale (IMS) and Short Physical Performance Battery (SPPB) against the PFIT-s; (2) the construct validity of these tests against muscle strength; (3) predictive utility of these tests to predict discharge to home; and (4) the clinical applicability. This was a nested study within an ongoing controlled study and an observational study.

Methods

Sixty-six individuals were assessed at awakening and ICU discharge. Measures included: PFIT-s, FSS-ICU, IMS and SPPB. Bivariate relationships (Spearman’s rank correlation coefficient) and predictive validity (logistic regression) were determined. Responsiveness (effect sizes); floor and ceiling effects; and minimal important differences were calculated.

Results

Mean ± SD PFIT-s at awakening was 4.7 ± 2.3 out of 10. On awakening a large positive relationship existed between PFIT-s and the other functional measures: FSS-ICU (rho = 0.87, p < 0.005), IMS (rho = 0.81, p < 0.005) and SPPB (rho = 0.70, p < 0.005). The PFIT-s had excellent construct validity (rho = 0.8, p < 0.005) and FSS-ICU (rho = 0.69, p < 0.005) and IMS (rho = 0.57, p < 0.005) had moderate construct validity with muscle strength. The PFIT-s and FSS-ICU had small floor/ceiling effects <11% at awakening and ICU discharge. The SPPB had a large floor effect at awakening (78%) and ICU discharge (56%). All tests demonstrated responsiveness; however highest effect size was seen in the PFIT-s (Cohen’s d = 0.71).

Conclusions

There is high criterion validity for other functional measures against the PFIT-s. The PFIT-s and FSS-ICU are promising functional measures and are recommended to measure function within the ICU.

Trial registration

Clinicaltrials.gov NCT02214823. Registered 7 August 2014).

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0829-5) contains supplementary material, which is available to authorized users.

Assessment of impairment and activity limitations in the critically ill: a systematic review of measurement instruments and their clinimetric properties

PURPOSE

To identify measures used to evaluate the broad constructs of functional impairment and limitations in the critically ill across the continuum of recovery, and to evaluate, synthesise and compare the clinimetric properties of the measures identified.

METHODS

A systematic review of articles was carried out using the databases Medline (1950-2014), CINAHL (1982-2014), EMBASE (1980-2014), Cochrane Library (2014) and Scopus (1960-2014). Additional studies were identified by searching personal files. Eligibility criteria for selection: Search 1: studies which assessed muscle mass, strength or function using objective non-laboratory measures; Search 2: studies which evaluated a clinimetric property (reliability, measurement error, validity or responsiveness) for one of the measures identified in search one. Two independent reviewers assessed articles for inclusion and assessed risk of bias using the consensus-based standards for selection of health status measurement instruments checklist.

RESULTS

Thirty-three measures were identified; however, only 20 had established clinimetric properties. Ultrasonography, dynamometry, physical function in intensive care test scored and the Chelsea critical care physical assessment tool performed the strongest for the measurement of impairment of body systems (muscle mass and strength) and activity limitations (physical function), respectively.

CONCLUSIONS

There is considerable variability in the type of measures utilized to measure physical impairments and limitations in survivors of critical illness. Future work should identify a core set of standardized measures, which can be utilized across the continuum of critical illness recovery embedded within the International Classification of Functioning framework. This will enable improved comparisons between future studies, which in turn will assist in identifying the most effective treatment strategies to ameliorate the devastating longer-term outcomes of a critical illness.

The General Weakness Syndrome Therapy (GymNAST) study: protocol for a cohort study on recovery on walking function

INTRODUCTION

Critical illness myopathy (CIM) and polyneuropathy (CIP) are common complications of critical illness that frequently occur together. Both cause so called intensive care unit (ICU)-acquired muscle weakness. This weakness of limb muscles increases morbidity and delay rehabilitation and recovery of walking ability. Although full recovery has been reported people with severe weakness may take months to improve walking. Focused physical rehabilitation of people with ICU-acquired muscle weakness is therefore of great importance. However, although physical rehabilitation is common, detailed knowledge about the pattern and the time course of recovery of walking function are not well understood. Therefore, the aim of the General Weakness Syndrome Therapy (GymNAST) study is to describe the time course of recovery of walking function and other activities of daily living in these patients.

METHODS AND ANALYSIS

We conduct a prospective cohort study of people with ICU-acquired muscle weakness with defined diagnosis of CIM or CIP. Based on our sample size calculation, approximately 150 patients will be recruited from the ICU of our hospital in Germany. Amount and content of physical rehabilitation, clinical tests for example, muscle strength and motor function and neuropsychological assessments will be used as independent variables. The primary outcomes will include recovery of walking function and mobility. Secondary outcomes will include global motor function, activities in daily life and participation.

ETHICS AND DISSEMINATION

The study is being carried out in agreement with the Declaration of Helsinki and conducted with the approval of the local medical Ethics Committee (Landesärztekammer Sachsen, Germany, reference number EK-BR-32/13-1) and with the understanding and written consent of each patient's guardian. The results of this study will be published in peer-reviewed journals and disseminated to the medical society and general public.