Prioritizing Rehabilitation Strategies in the Care of the …...Prioritizing Rehabilitation...

QU A R T E R LY EV I D E N C E-B A S E D RE V I E W S O N CUR R E N T TO P I C S I N

CR I T I C A L CA R E ME D I C I N E B Y L E A D I N G CA N A D I A N CO N T E N T EX P E R T S

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Acknowledgements:

Canadian Institutes of Health ResearchPublic Health Agency of Canada

John Granton, MDChair, Canadian Critical Care Society

John Marshall, MDChair, Canadian Critical CareTrials Group

Margaret Herridge, MDEditor, Critical Care Rounds

Over the past decade, prospective studies have revealed that a significant proportionof survivors of critical illness suffer from profound neuromuscular weakness andconsequent impairment in functional status and quality of life. Immobility, deepsedation, and inflammation likely contribute to the development of intensive careunit-acquired weakness (ICUAW). Clinical trials suggest that early rehabilitationduring acute critical illness may minimize ICUAW and improve patient-centred out-comes. Therapeutic strategies must incorporate a paradigm shift where multidisci-plinary efforts at early mobilization are prioritized and supported. Canadian andinternational efforts are currently underway to identify barriers and to evaluate novelinterventions. This issue of Critical Care Rounds reviews ICUAW, summarizes recentclinical trials on early rehabilitation in the ICU, and highlights novel strategies thatmay minimize the burden of this syndrome.

Enforced bed rest and deep sedation are common in traditional ICUs; however,emerging evidence suggests that these interventions are of little clinical benefit and poten-tially harmful.1 The care of critically ill patients is typically focused on efforts to restoreacute organ function, with little attention paid to the preservation of neuromuscular struc-ture and function. Over the past 2 decades, there has been growing awareness that immo-bility contributes to the pathogenesis of neuromuscular weakness, which, in turn, canadversely affect clinically important outcomes and functional recovery beyond the ICU.

Epidemiology of ICUAW

The reported incidence of ICUAW varies depending on how it is defined and the pop-ulation studied. In a systematic review of 24 studies using both clinical and electrophysio-logical testing, 655 of 1421 (46%) critically ill patients experienced neuromuscular compli-cations, which were associated with increased duration of mechanical ventilation and lengthof ICU and hospital stay.2 In a prospective cohort of 95 patients mechanically ventilated forat least 7 days, clinically defined ICUAW was found in 25% of patients.3 In anotherprospective study utilizing electrophysiological testing, the incidence of ICUAW was 58%for patients ventilated for at least 7 days.4 Among patients with sepsis, the incidence ofICUAW has been reported to be as high as 50%-100%.5,6

Taxonomy of ICUAW

Critically ill patients can acquire different types of neuromuscular dysfunction,including the following:• polyneuropathy, characterized by a sensory-motor axonopathy• myopathy, with metabolic, inflammatory, and bioenergetic muscle derangements and/or

functional inactivation (ie, membrane inexcitability)• polyneuromyopathy, with combined muscle and nerve involvement

One of the first descriptions of critical illness polyneuropathy and myopathy was byBolton and colleagues7 in 1984 in a case series of 5 patients with flaccid and areflexic limbs

Prioritizing Rehabilitation Strategiesin the Care of the Critically IllB Y K A R E N K . Y. K O O , M D , K A R E N C H O O N G , M B , M S C , A N D E D D Y F A N , M D

®

The editorial content ofCritical Care Rounds is determinedsolely by the Canadian CriticalCare Society.

Dr. Koo is an Assistant Professor andCritical Care Consultant, Division ofCritical Care, Department of Medicine,University of Western Ontario, London,Ontario. Dr. Choong is a Pediatric CriticalCare Consultant and Associate Professor,Department of Paediatrics, McMasterUniversity, Hamilton, Ontario.Dr. Fan is a Critical Care Consultant,Interdepartmental Division of Critical CareMedicine, University of Toronto, Toronto,Ontario.

Disclosure: The authors have no disclosureswith regard to the contents of this issue.

who were unable to wean from mechanical ventilation.Electrophysiological testing demonstrated severelyreduced motor and sensory nerve action potential ampli-tudes. The nerve histopathology of affected individualsshowed moderate to severe primary axonal polyneu-ropathy with mixed motor and sensory involvement anddistal predominance. Latronico and colleagues8 subse-quently described a case series of 24 ventilator-dependentpatients with a primary myopathy in addition to axonaldegeneration in nerve-affected patients. Examination ofthe histopathology of the peroneus brevis musclerevealed that 58% of these individuals had evidence ofprimary myopathy, 21% had polyneuromyopathy, and92% had muscle atrophy. As polyneuropathy andmyopathy may coexist in the critically ill patient, and isoften difficult to distinguish, this syndrome of neuromus-cular derangements is now collectively referred to asICUAW.

Pathophysiology and Risk Factors of ICUAW

Many risk factors have been implicated in the devel-opment of ICUAW, including physical inactivity,muscle unloading, inflammation, certain medications,and hyperglycemia. Although bed rest has been thoughtto be necessary for recovery, prolonged immobilitybeyond 24-48 hours is associated with many detrimentalphysiological consequences (Figure 1).9 Bed-boundpatients sustain muscle atrophy from the loss ofmechanical loading required to maintain musclelength.12 These unloaded muscles have fewer actin fila-ments, resulting in a lower force per cross sectionalarea, which manifests clinically as muscle weakness.12

Unloaded muscles also have decreased protein syn-thesis13 and accelerated protein degradation.14,15 Muscleatrophy may occur within hours of immobility inhealthy subjects,16 leading to up to 5% loss of musclestrength for each week of bed rest.17 Immobilityincreases production of proinflammatory cytokines andreactive oxygen species, resulting in further muscle pro-teolysis, with a net loss of muscle protein and subse-quent muscle weakness.18

The interaction of critical illness with immobility canfurther accelerate muscle loss.19 Catabolic protein losscan be up to 2% per day in critically ill patients.20 Themuscle fibre area decreases by 4% per day with severeatrophy in contractile myosin filaments.21 Increasedseverity of illness has also been associated withICUAW.4,22,23 The systematic inflammatory responsesyndrome in the context of inactivity has a more pro-found impact on muscle loss than with immobilizationalone.24,25 Inactive septic patients experience decreasedmuscle protein synthesis, increased urinary nitrogenexcretion (suggesting increased muscle catabolism), anddecreased lower extremity muscle mass.26

The evidence with respect to corticosteroids andneuromuscular blocking agents is inconsistent. Cortico-steroid use has been associated with significant muscleatrophy in animal studies.27 While observational studiesin humans have not confirmed a significant associationbetween corticosteroids and ICUAW,28-30 post hoc analysisof a randomized controlled trial (RCT) evaluating use ofmethylprednisolone in acute respiratory distress syn-drome (ARDS) showed that ICUAW occurred onlyamong subjects in the corticosteroid group.31 In patientsmechanically ventilated for at least 7 days, the use ofcorticosteroids significantly increased the risk of devel-oping ICUAW (odds ratio 14.9), but there was no associ-ation with dose or duration of corticosteroid use.4

Neuromuscular blocker use was shown to be an inde-pendent risk factor for ICUAW in one observationalstudy; however, this was not replicated in large prospec-tive studies.4,24,32 In a recent RCT of 2-day cisatracuriuminfusion in patients with ARDS, ICUAW (as measuredby Medical Research Council [MRC] scores) at day 28 orICU discharge was no different in the cisatracuriumgroup (178 patients) versus those who received placebo(162 patients).33 However, performance of MRC testingmay not have been standardized and no functional assess-ment of neuromuscular function was made at ICU dis-charge or beyond. Furthermore, the MRC score is aglobal measure of overall muscle strength and thus wouldbe insensitive to the detection of weakness in individualmuscle groups. Hyperglycemia has also been associatedwith ICUAW, and there is some evidence to suggest thattighter glycemic control may be protective.34

The Burden of ICUAW in the Critically Ill

Persistent physical and nonphysical impairment iscommon in patients recovering from critical illness. Her-ridge and colleagues35 prospectively studied 109 ARDSsurvivors and found persistent functional disability 1 yearafter discharge from the ICU. On average, patients hadsevere muscle atrophy and lost 18% of their baseline bodyweight in the ICU. Patients stated that their physicalfunctional impairment was due to loss of muscle bulk,proximal muscle weakness, and fatigue. Entrapment neu-ropathies, foot drop, joint immobility, persistent pain atchest tube insertion sites, and dyspnea were also describedby patients. At 1 year, over one-half of the patients couldnot return to work because they still experienced fatigueand weakness and poor functional status. Beyond thephysical disability is growing awareness that ICU sur-vivors are also burdened by nonphysical morbidity,including depression, anxiety, post-traumatic disorder,delirium, and cognitive impairment.10 The global impactof severe critical illness may result in debilitating disabilitythat results in ongoing requirements for medical care,financial strain, and caregiver burnout (Figure 1).10,11

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CRITICAL CARER O U N D S





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CRITICAL CARER O U N D S2

Diagnosis of ICUAW

The diagnosis of ICUAW remains challenging.A patient with weakness may have polyneuropathy,myopathy, or both (ie, polyneuromyopathy). Somepatients without significant features of neuropathic ormyopathic changes may still have significant weaknessfrom muscle atrophy alone. Many critically ill patientsare exposed to prolonged immobility, systemic inflamma-tion, and oversedation, putting a large number at risk forthe development of ICUAW. However, routine screeningof all ICU patients with electrophysiological testing(ie, nerve conduction studies and/or electromyography[EMG]) is not feasible, due to problems with cost andavailability of both equipment and expertise, as well aschallenges in testing (eg, due to limb edema) and inter-pretation of the results in critically ill patients. EMG candetect abnormal muscle activity in the forms of fibrilla-tion potentials and positive sharp waves; however, thesefindings suggest either a neuropathy or myopathy. Apatient’s collaboration is required to evaluate the minimalor maximal voluntary contraction during an EMG test todistinguish neuropathic from myopathic processes.There are presently no efficacious treatments for criticalillness myopathy or polyneuropathy. Thus, we advocate

that a clinical approach to the recognition of functionalweakness in an individual patient remains more usefulthan any attempts at identifying the precise etiology(Table 1).

Early Mobilization in Critically Ill Patients

There is accumulating evidence that early and accel-erated rehabilitation improves both short- and long-termmorbidity in specific groups of hospitalized patients suchas those affected by critical illness,36 community-acquiredpneumonia,37 exacerbations of chronic obstructive pul-monary disease,38 mild traumatic brain injury,39 stroke,40-

43 myocardial infarction,44-46 deep-vein thrombosis,47-49

and infectious hepatitis.50 In 2007, Bailey and colleagues51

demonstrated that it was feasible and safe to instituteearly mobilization in mechanically ventilated, critically illpatients. In a cohort of 103 patients activated within thefirst 24 hours of admission to a respiratory ICU (2 dailysessions of physiotherapy lasting at least 30 minutes),69% of participants were able to ambulate more than 30m (100’) prior to ICU discharge, and adverse events wererare. In a similar cohort of 104 patients promptlyimmersed in physical activity, 88% were able to walk over60 m (200’) prior to ICU discharge.52 However, neitherstudy included comparative control groups.





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Figure 1: Physiological sequelae of immobilization and the burden of severe critical illness.

PHYSIOLOGICAL HARMS OF PROLONGED IMMOBILIZATION9

BURDEN OF SEVERE CRITICAL ILLNESS10,11

Cardiovascular Respiratory Neuromuscular

Physical disability Non-physical disability Other QOL issues

Other effects

• Orthostaticintolerance

• ↓ Stroke volume• ↓ Cardiac output• ↓ Peripheral vascularresistance

• Microvasculardysfunction

• ↓ Peak VO2

• Hypoxia• Atelectasis• Pneumonia• ↓ MIP & FVC• Mechanicalventilatorydependence

• ICUAW– polyneuropathy– myopathy– polyneuro-myopathy

– muscle atrophy• Joint contractures• ↓ Bone density

• Thromboembolism• Insulin resistance• ↓ Aldosterone andrenin

• ↑ Atrial natriureticpeptide

• Pressure ulcers

• Neuropathy and/ormyopathy

• Fatigue• Pulmonary dysfunction• Joint immobility• Pain (eg, chest/feeding tubeinsertion site)

• PTSD• Cognitive impairment• Depression• Anxiety• Delirium• Insomnia

• Caregiver burnout• Financial strain• Relationship strain & change(eg, family, coworkers)

ICUAdmission

Short-term

Morbidity

&

IncreasedICU &

HospitalLOS

Long-termMorbidity

ICU = intensive care unit; VO2 = oxygen delivery; MIP = maximal inspiratory pressure; FVC = forced vital capacity;ICUAW = ICU-acquired weakness; PTSD = post traumatic stress disorder; LOS = length of stay; QOL = quality of life

Nava53 conducted an RCT of an early activityapproach in a respiratory ICU. The intervention pro-tocol consisted of early ambulation for 30 minutes twicedaily combined with passive range of motion to extremi-ties and use of a treadmill even during mechanical venti-lation. Patients mobilized early had longer 6-minute walkdistances by ICU discharge and mean inspiratory pres-sures (during mechanical ventilation) than patients ran-domized to usual care. In 2008, Morris54 demonstratedthat a proactive mobility team (physical therapist, regis-tered nurse, and health aid), in combination with auto-mated orders for physiotherapy, reduced ICU and hos-pital length of stay. In a recent trial by Schweickert andcolleagues,36 104 patients were randomized to eitherearly mobilization during periods of interrupted sedationversus interrupted sedation alone. Early ambulationresulted in significant improvement in composite inde-pendent neuromuscular function at hospital discharge(relative risk reduction 24%) compared to usual care.There were fewer days of delirium and days on mechan-ical ventilation in those receiving therapy sooner.

Pediatric Considerations

The epidemiology, diagnosis, and clinical sequelae ofprolonged immobility and ICUAW in critically ill chil-dren are less well characterized than in adult patients. Ourcurrent knowledge of ICUAW in children is restricted toa number of case series and a single prospective observa-tional study.53-58 From these preliminary studies, sepsis,multiorgan failure, organ transplantation, status asth-maticus, and exposure to corticosteroids and neuromus-

cular blockade have been implicated as potential riskfactors for the development of ICUAW in children.57 Inthe only prospective pediatric study to date, Banwell andcolleagues55 reported an overall incidence of ICUAW of1.7% in children who stayed in a pediatric critical careunit (PCCU) for at least 24 hours. This incidenceincreased to 5% in children who were ventilated for atleast 5 days. The patients in this study were screened byclinical examination, and hence it has been suggested thatthis study underestimates the true incidence of ICUAWin children, as the physical examination is insensitive andmay miss up to 50% of cases.59 The mean age in thiscohort was 12.3 years (range 1.6-17.7), which may be areflection of the inherent difficulty in performing adetailed neurological examination in the pediatric popula-tion, particularly in infants, noncompliant children, orchildren with underlying disabilities. The onset ofICUAW in children is also variable in the literature,ranging from as early as 2 to 20 days.60,61 Consequently,ICUAW in this age group is likely underrecognized andthe true incidence in children remains unclear.

Children who survive critical illness can experienceneurocognitive and functional morbidity,62 which in turncan have a significant impact on school performance andquality of life.63 Prolonged immobility and ICUAW havebeen implicated as risk factors for poor functionalrecovery in these children.57 Prospective evidence islimited; however, current reports suggest that ICUAWmay be associated with ventilatory dependence, pro-longed hospital stay, and persistent neuromuscular weak-ness.55 As PCCU mortality rates continue to improve, the





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Table 1: Diagnostic approach to ICU-acquired weakness

COPD = chronic obstructive pulmonary disease; EMG = electromyography; NCS = nerve conduction study; CK = creatine kinase

Onset ofCritical Illness/ICU Admission

PatientAwakening

Resolution ofNon-Neuromuscular

Organ FailureICU Discharge

Diagnosticquestion

Are there pre-morbid orother causes ofweakness present?

Is the patient sedatedand/or delirious?

Is there peripheralmuscle weakness and/orfailure to wean frommechanical ventilation?

Is there severe andpersistent muscleweakness and/or failureto wean frommechanical ventilation?

Diagnosticconsiderations

Consider premorbidweakness due to chronicdiseases (eg, COPD)and/or non-ICU acquiredcauses of weakness (eg,stroke, demyelinatingdiseases)

Minimize heavy sedationusing goal-directedsedation and/or dailyinterruption to allow forserial neurologicalexamination

Diffuse, symmetricalmuscle weakness withpreserved/depresseddeep tendon reflexes isconsistent with ICUAW

Patients with severe andnon-resolving weaknessmay warrant furthertesting and/or specialistconsultation

Investigations Obtain history ofpremorbid physicalfunction and rule outnon-ICU acquired causesof weakness

Serial evaluations ofsedation and deliriumstatus

Serial neurologicalexamination

Consider consultationwith a neurologistand/or physiatrist, andEMG/NCS, muscleenzymes (e.g., CK),and/or muscle biopsy

proportion of critically ill children with chronic condi-tions and disabilities is increasing significantly.64 Thus,the need for acute rehabilitation in the pediatric popula-tion is of great importance. While the benefits of earlymobilization have been demonstrated in some criticallyill medical and surgical adults, this has yet to be specifi-cally evaluated in PCCU patients. However, the timingof rehabilitation has been shown to be important in opti-mizing recovery in subpopulations of critically ill chil-dren such as those with traumatic brain injury65 and fol-lowing corrective congenital cardiac surgery.66

Challenges to Acute Rehabilitation in the ICU

Acute rehabilitation is not uniformly delivered acrossICUs.67,68 Multiple patient, provider, and institutionalbarriers, either actual or perceived, prevent early mobi-lization. Medical instability, endotracheal intubation,physical restraints, the presence of lines or devices, cog-nitive impairment, excessive sedation, inadequate anal-gesia, obesity, and inadequate nutrition frequentlyprevent routine physical therapy in the critically ill.Limited resources and personnel to routinely mobilizeICU patients has been reported in national surveysacross India,69 Europe,67 Canada,70,71 and the US.68

Twenty-five percent of European ICUs and 20% ofIndian ICUs do not have designated physiotherapists.67

Providers may have concerns about the safety of earlymobilization and feel inadequately trained to ambulatemechanically ventilated patients.71 These concerns arefurther compounded by few consensus guidelines onwhen patients are suitable candidates for rehabilita-tion.72,73 In a national survey of American hospitals, only10% of all ICUs had established initiation criteria foractivity and fewer than 1% of all ICUs had automaticphysiotherapy requests.68 Portable ventilators, walkers,and ceiling lifts are often insufficient. Hospital adminis-trators may perceive the intervention of early rehabilita-tion in the ICU to be costly. However, the potential fordecreased ICU and hospital length of stay from earlyrehabilitation programs may lead to enhanced resourceutilization and improved patient satisfaction, resulting ina net cost savings on a larger scale.74

Mobility champions and multidisciplinary teamefforts have been of paramount importance in creatingenvironments that support the provision of timely andeffective rehabilitation.75 The recognition of local bar-riers through a review of existing practices and discussionwith healthcare providers from the disciplines of nursing,physical therapy, respiratory medicine, occupationaltherapy, critical care physicians, neurologists, and reha-bilitation experts have led to the creation of simple ICUrehabilitation guidelines and educational initiatives topromote early mobilization.72,73 With the growingnumber of critically ill patients in the context of already

financially strained hospitals, clinicians will have aresponsibility to advocate for resources and develop moreefficient ways to sustain rehabilitation efforts.

Future Directions

Further studies are needed to fully elucidate the mech-anisms by which immobility and other aspects of criticalillness lead to ICUAW. Currently, there are limited inter-ventions to prevent or treat ICUAW, with tight glycemiccontrol having the greatest supporting evidence. Emergingdata demonstrate the safety, feasibility, and potentialbenefit of early mobility in critically ill patients with theneed for multicentre randomized trials to evaluate poten-tial short- and long-term benefits of early mobility andother novel treatments (eg, neuromuscular electrical stim-ulation, myostatin inhibitors) on patients’ muscle strength,physical function, quality of life, and resource utiliza-tion. Elucidating local barriers, developing guidelines tofacilitate early mobilization, advocating for appropriatestaffing, and nurturing a culture that prioritizes rehabilita-tion as an integral part of critical care are important stepsin building a sustainable recovery program. Evaluating theongoing benefits of proactive rehabilitation as patientstransition from the ICU to the ward and to the commu-nity would also be of interest. Finally, the putative benefitsof early mobilization in other populations of critically illpatients (eg, pediatric, surgical, trauma, neurological) needto be explored in future clinical trials.

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