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October 2011
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Mobility Lost in the ICU Spotlight Case
Commentary by Jim Smith, PT, DPT, MA

Case Objectives

 


  • Describe the role of the physical therapist in the hospital and ICU.
  • Compare the risks from immobility with the benefits gained from a program of therapeutic exercise.
  • Identify criteria that indicate a patient is appropriate for physical therapy.
  • List exercise contraindications and guidelines for a patient in the ICU.
  • Describe potential exercises and activities for a patient in the ICU.

The Case

 


A 56-year-old man with insulin-dependent diabetes, hypertension, and chronic kidney disease was admitted to a trauma service after injuries suffered from an assault and battery. The patient's injuries included a left shoulder dislocation and a minimally displaced fracture of a thoracic vertebral body without any neurologic compromise. Shortly after admission, the patient developed altered mental status and increasing hypoxia, requiring mechanical ventilation. This led to a prolonged intensive care unit (ICU) stay for respiratory failure from an ischemic cardiac event and aspiration pneumonia.

Following 6 weeks of hospitalization, the patient was significantly deconditioned despite slow and steady improvements overall. As he was transferred out of the ICU, the physical therapist (PT) was consulted to assist in the rehabilitation process. After reviewing the medical records, the PT noted the initial shoulder injury on admission. In addition to providing a general assessment, the PT expressed concern that the shoulder injury had now progressed to involve significant limitation in range of motion and function with associated pain. The PT felt this may have been preventable with earlier and aggressive physical therapy interventions while in the ICU.

The Commentary

 

The complications encountered by this patient are not unusual, as the decrease in physical activity that accompanies hospitalization carries adverse effects for the cardiovascular, hematologic, musculoskeletal, pulmonary, and psychiatric systems.(1) Critically ill patients are at highest risk since they can develop ICU-acquired weakness due to polyneuropathy, myopathy, or a combination of these conditions.(2) As patients begin to encounter the cascade of complications that often deem them "too sick" for physical therapy, an early referral to a PT is in fact the best strategy to prevent or treat weakness and deconditioning.(3) The patients who benefit most from physical therapy are those who have lost functional abilities when compared to their pre-hospitalization status and who consent and actively participate with interventions.(4) The case presented illustrates a common clinical scenario when the acute medical issues of a patient appropriately occupy the focus of providers, and only when they are less acute is a PT involved. This approach is a strategy for poor recovery from acute illness and a lost opportunity to prevent, or at least minimize, the impact of hospital-acquired deconditioning.

Role of the Physical Therapist in the Hospital Setting

A hospital's rehabilitation department includes occupational therapists (OTs) and PTs who provide services to patients that need to achieve or restore function. There is a complementary relationship between OTs, who provide services that use activities to foster the attainment of abilities, and PTs, who use therapeutic exercises to facilitate improvement in function.

Rehabilitation providers are educated with a graduate degree, and most education programs prepare the PT with a doctor of physical therapy (DPT) degree. PTs obtain specialized skills to tailor their practice to the setting, such as hospitals, outpatient clinics, or school systems.(5) The hospital-based PT will examine patients to identify impairments (e.g., weakness or reduced aerobic capacity) and functional limitations (e.g., ability to manage personal hygiene or climb stairs). This initial evaluation will inform the plan of care and guide recommendations for an appropriate discharge from the hospital. While not every patient admitted to a hospital requires a physical therapy evaluation, patients most likely to benefit include those with a decreased functional status following admission, neurologic or cardiopulmonary pathology that affects function, or an acute musculoskeletal injury such as the one noted in this case.

The PT's plan of care focuses on interventions to improve or restore mobility and function. Interventions include patient-specific exercises that increase flexibility, teach new movement strategies (e.g., following a stroke or learning to use crutches), or increase capacity for activity (e.g., in the presence of a medication change or recent surgery). Most interventions are designed to intentionally stress systems to achieve increases in strength or aerobic capacity. These stress-inducing activities require close monitoring of patient responses, and adjustment of the intensity if necessary, so that treatment is safely within their physiologic capacity.

The PT's prognosis addresses the patient's requirements at the time of hospital discharge. The PT integrates information about the patient's goals and functional abilities, the capacity and timeline to improve those abilities, the discharge environment (e.g., availability of assistance and accessibility of the home), safety, and the types of services the patient will require. PTs make accurate and appropriate recommendations for discharge, and when their recommendations are not followed, the patient is almost three times more likely to be readmitted to the hospital within 30 days.(6) Patients who have the capacity to benefit from intensive rehabilitation services (i.e., 3 or more hours daily) will be referred to an inpatient rehabilitation facility. Others are more likely to achieve optimal outcomes through a subacute facility, home care, or outpatient services.(4)

Role of Physical Therapy in the ICU Setting

In the past, physicians generally waited to refer critically ill patients to the PT until the transfer out of the ICU, a scenario illustrated in this case. While this was driven by the belief that patients in the ICU were too sick to safely participate in physical therapy, this practice is changing. This 56-year-old patient in the ICU has risk for complications due to prolonged mechanical ventilation and inactivity. Weakness and deconditioning complicate the clinical course and prolong ICU stays (2,3), with resulting impairments and activity limitations that may or may not resolve.(7) Complications are prevented or reduced through interventions from a PT.(8) In most ICUs, a physician's referral initiates consultation with a PT, although criteria for initiation are poorly defined and less than 10% of hospitals have identified criteria for appropriate referrals.(9) While therapy may have reduced this patient's shoulder limitations and pain, immediate priorities would focus on preventing generalized deconditioning and promotion of weaning from the ventilator to reduce ICU length of stay.(10)

There is rapid growth of evidence about the benefits of exercising ICU patients.(11-13) Similar to non-ICU patients, a PT will start by setting goals that include overcoming physical impairments (e.g., insufficient aerobic capacity or weakness) and activity limitations (e.g., inability to get out of bed or to ambulate). The resulting plan of care may include exercises that foster beneficial physical adaptations through therapeutic activities of appropriate intensity, duration, and frequency. Each plan is customized to approach the limits of the patient's strength or metabolic capacity. The PT evaluates the patient's response to these interventions, so the ICU is a preferred environment for providing services because of the easy access to physiologic data for monitoring.(14)

There are 3 distinct sets of criteria to inform decision-making for exercising patients in the ICU. As described in Table 1, the first are inclusion criteria to identify appropriate candidates for a physical therapy program. The second identifies contraindications for engaging in physical therapy, and the third details termination thresholds to inform the PT when to stop or modify an exercise session.

As the termination thresholds illustrate, the PT must attend to moment-to-moment responses. For many patients, a response that exceeds a termination threshold may not indicate an inability to participate in a specific exercise. Rather, it suggests that the mode, intensity, or duration of the exercise must be titrated to accommodate the patient's current capacity. It's also important that the PT communicate with the patient's bedside nurse or physician(s) about changes in a patient's condition, which may indicate or prompt the need for additional medical evaluation.

Shifting the Physical Therapy Paradigm in the ICU

Perme and Chandrashekar (2008) summarized "physical therapy interventions in the ICU can include positioning, postural drainage, airway clearance, breathing retraining, therapeutic exercises, inspiratory muscle training, transfers, gait re-education, and patient/family education."(15) Providers need to balance the need to achieve physical therapy goals with those that put patients at risk for discomfort. For instance, sedation may need to be interrupted to achieve an optimal response from physical therapy interventions.(13) On the other hand, the ability to promote upright positions achieves the increase of lung volume and gas exchange while reducing cardiac compression and stress.(3) Strategies for mobilizing and advancing activity in ICU patients with respiratory failure are described in Table 2.(10)

Innovative technology also enhances exercise in the ICU, such as exercise with a bicycling ergometer that can be used in supine or semi-recumbent positions (17), or weight-bearing exercise with a dynamic tilt table that grades the level of resistance.(18) Devices that accommodate to the patient's abilities decrease the physical demands placed on the caregivers, and allow for precision in designing exercise programs. Regardless of the strategy to mobilize ICU patients, multidisciplinary teamwork and a culture that expects patient mobility is required. For example, ambulating a patient may require the PT to determine the activity intensity and to assist the patient, the respiratory therapist to manage the ventilator and respiratory issues, the nurse to assist with lines and tubes connected to the patient, and an aide to follow with a wheelchair.(15) Through collaboration, improved patient outcomes can be achieved with no increase in costs, and may reduce overall costs by reducing ICU length of stay.(10) A patient on a ventilator riding a stationary bike or ambulating in the ICU is perhaps the most powerful image in the shifting paradigm of increased mobility in this setting. A culture that expects this level of activity—in contrast to a tradition that encourages bedrest and sedation—is the greatest challenge to improving outcomes.(19,20) Needham and colleagues (21) elaborate on processes to promote physical activity and reduce sedation for patients on mechanical ventilation, with resulting improvements in functional abilities, decrease in delirium, and shortened length of stay in the ICU and hospital. The description of the processes they applied is a resource for institutions that are implementing comprehensive changes in the ICU.(21)

Typically the sequelae of weakness, reduced aerobic capacity, and persisting disability follow a stay in the ICU. Evidence shows that many of these effects are preventable with a customized program of exercise and activity. These interventions are safe, well-tolerated, and feasible, as demonstrated by the very low incidence of adverse responses accompanying physical therapy interventions.(10,12,13,17) Patients in the ICU are sick, but most are not too sick to participate in physical therapy and benefit from exercise, upright activities, and ambulation. Physical therapy preserves and restores the patients' functional abilities and accelerates discharge from the hospital.

In the case presented, we don't know the exact details to identify when the patient would have benefited from a physical therapy program, but we're confident it was before he transferred out of the ICU. The initial plan of care should have incrementally provided cardiac and respiratory conditioning while protecting the shoulder and spine, with movement and exercise added to those structures as healing progressed.

Proposed System Changes

Initiatives to reduce expenses in hospitals have caused rehabilitation departments to downsize, which results in fewer PTs to provide services to patients. Therefore, it is important to be judicious when consulting a PT. Passive services (e.g., passive range of motion) or routine activities (e.g., need for ambulation) generally are not skilled services and should not be referred to a PT; referrals should be reserved for those patients who can participate and benefit from interventions. Developing clinical guidelines (or criteria and triggers for referral) is a recommended approach to optimize a limited resource while providing a critical need to patients. With growing reliance on electronic health records and CPOE, systems that potentially prompt or guide providers through these avenues may prove useful.

The preferred strategy to identify and manage ICU candidates for physical therapy is designating a PT for each ICU, and having that PT participate in patient care rounds. The limited resources in many departments will result in tension between participation in rounds and the capacity to provide treatment to patients, but this designation will improve collaboration between the PT and the ICU team. Measuring the impact of this designation by tracking ICU length of stay may serve to build a greater business case for hospital leadership as well.

Take-Home Points

  • A PT's plan of care focuses on interventions to improve or restore mobility and function. Interventions include patient-specific exercises that increase flexibility, teach new movement strategies, or increase capacity for activity.
  • Patients may achieve shorter hospitalization and avoid long-term complications through early involvement of a PT.
  • The benefits of mobility outweigh the risks from immobility for many patients in the ICU. These benefits include fewer short- and long-term complications, and reduced length of stay.
  • Early patient mobility in the ICU requires a culture shift that embraces mobilization and collaboration among all members of the team.
  • Hospitals should institute guidelines or criteria to prompt referral for physical therapy services.


Jim Smith, PT, DPT, MA

Associate Professor of Physical Therapy

Utica College


Faculty Disclosure: Dr. Smith has declared that neither he, nor any immediate member of his family, have a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, the commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.



References

1. Malone DJ. Bed rest, deconditioning, and hospital-acquired neuromuscular disorders. In: Malone DJ, Lindsay KLB, eds. Physical Therapy in Acute Care: A Clinician's Guide. Thorofare, NJ: Slack, Inc.; 2006:93-110. ISBN: 9781556425349.

2. Schweickert WD, Hall J. ICU-acquired weakness. Chest. 2007;131:1541-1549. [go to PubMed]

3. Gosselink R, Bott J, Johnson M, et al. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med. 2008;34:1188-1199. [go to PubMed]

4. Malone DJ, Adler J. Acute care physical therapy examination and discharge planning. In: Malone DJ, Lindsay KLB, eds. Physical Therapy in Acute Care: A Clinician's Guide. Thorofare, NJ: Slack, Inc.; 2006:1-30. ISBN: 9781556425349.

5. Masley PM, Havrilko CL, Mahnensmith MR, Aubert M, Jette DU. Physical therapist practice in the acute care setting: a qualitative study. Phys Ther. 2011;91:906-919. [go to PubMed]

6. Smith BA, Fields CJ, Fernandez N. Physical therapists make accurate and appropriate discharge recommendations for patients who are acutely ill. Phys Ther. 2010;90:693-703. [go to PubMed]

7. Cox CE, Docherty SL, Brandon DH, et al. Surviving critical illness: acute respiratory distress syndrome as experienced by patients and their caregivers. Crit Care Med. 2009;37:2702-2708. [go to PubMed]

8. Chiang LL, Wang LY, Wu CP, Wu HD, Wu YT. Effects of physical training on functional status in patients with prolonged mechanical ventilation. Phys Ther. 2006;86:1271-1281. [go to PubMed]

9. Hodgin KE, Nordon-Craft A, McFann KK, Mealer ML, Moss M. Physical therapy utilization in intensive care units: results from a national survey. Crit Care Med. 2009;37:561-566. [go to PubMed]

10. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility in the treatment of acute respiratory failure. Crit Care Med. 2008;36:2238-2243. [go to PubMed]

11. Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA. 2008;300:1685-1690. [go to PubMed]

12. Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35:139-145. [go to PubMed]

13. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373:1874-1882. [go to PubMed]

14. Dean E. Mobilizing patients in the ICU: evidence and principles of practice. Acute Care Perspect. 2008;17:1-9.

15. Perme C, Chandrashekar RK. Managing the patient on mechanical ventilation in ICU: early mobility and walking program. Acute Care Perspect. 2008;17:10-15.

16. Zanni JM, Needham DM. Promoting early mobility and rehabilitation in the intensive care unit. PT in Motion. 2010;2:32-38.

17. Burtin C, Clerckx B, Robbeets C, et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med. 2009;37:2499-2505. [go to PubMed]

18. Trees D, Coale N. Use of a dynamic tilt table for perambulation strength training of severely deconditioned patients. Acute Care Perspect. 2007;16:6-9.

19. Perme C, Chandrashekar R. Early mobility and walking program for patients in intensive care units: creating a standard of care. Am J Crit Care. 2009;18:212-221. [go to PubMed]

20. Thomsen GE, Snow GL, Rodriguez L, Hopkins RO. Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med. 2008;36:1119-1124. [go to PubMed]

21. Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil. 2010;91:536-542. [go to PubMed]

Tables


Table 1. Criteria to inform decision-making for exercising patients in the ICU.

Indications: A patient will benefit and should be referred to a PT when she/he is:
  • Mentally alert and able to follow simple commands
  • Hemodynamically stable
  • Maintaining adequate respiratory status with acceptable levels of oxygen saturation, with or without mechanical ventilator support (8,15,16)
  • At risk for complications preventable with early exercise and activity (12)
Contraindications: A patient should not engage in a session with a PT in the presence of:
  • Elevated intracranial pressure
  • Active gastrointestinal blood loss
  • Active myocardial ischemia
  • Agitation that required increased sedative administration in the past 30 minutes
  • An unsecure airway (13)
  • Hypoxia, with frequent desaturation below 88%
  • Hypotension with mean arterial pressure less than 65 mm Hg
  • New administration of a pressor agent or an antiarrhythmic agent
  • Change in ventilator setting for an increase in positive end-expiratory pressure or assist control mode (10)
Termination thresholds: The patient engaged in exercise must be monitored for signs and symptoms of cardiorespiratory distress. The activity should be modified or discontinued upon the development of:
  • Heart rate less than 40 beats/minute or more than 130 beats/minute
  • Respiratory rate less than 5 breaths/minute or more than 40 breaths/minute
  • Oxygen saturation less than 88%
  • Development of a new arrhythmia
  • Mean arterial blood pressure falls below 65 or rises above 110 mm Hg
  • Systolic blood pressure exceeding 200 mm Hg
  • Symptoms that raise concern for myocardial ischemia or airway device integrity
  • Patient distress as noted by non-verbal cues, gestures, or combativeness (13)
  • Neurological symptoms (e.g., development of ataxia or deterioration of mental status)



Table 2. Strategy for mobilizing ICU patients.

  • All patients receive passive range of motion to all extremities three times daily and a program of turning in bed every 2 hours within the nursing plan of care.
  • When patients can follow simple commands, interventions can include active-assisted and active range of motion to strengthen the extremities, and assist to a sitting position for 20 minutes, 3 times daily.
  • When the patient achieves fair strength in the biceps (3/5 on exam), progress to exercise sessions while sitting on the edge of the bed.
  • When the patient achieves fair strength in the quadriceps, progress out of bed for activities such as transfer training, balance activities (sitting or standing), and gait training. The activities advance in accord with the patient's response for the duration of the stay in the ICU.(10)