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Journal ArticleDOI: 10.1080/21679169.2019.1645880

Effects of intensive upright mobilisation on outcomes of mechanically ventilated patients in the intensive care unit: a randomised controlled trial with 12-months follow-up

04 Mar 2021-The European Journal of Physiotherapy (Taylor & Francis)-Vol. 23, Iss: 2, pp 68-78
Abstract: Objective: To examine effects of intensive upright mobilisation on short- and long-term outcomes in critically ill mechanically ventilated patients.Methods: A randomised controlled trial co...

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Topics: Intensive care unit (56%)
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Open accessJournal ArticleDOI: 10.1097/CCM.0000000000004382
Abstract: OBJECTIVES To assess the impact of rehabilitation in ICU on clinical outcomes. DATA SOURCES Secondary data analysis of randomized controlled trials published between 1998 and October 2019 was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. STUDY SELECTION We have selected trials investigating neuromuscular electrical stimulation or cycling exercises or protocolized physical rehabilitation as compared to standard of care in critically ill adults. DATA EXTRACTION Mortality, length of stay in ICU and at hospital, days on mechanical ventilator, and adverse events. DATA SYNTHESIS We found 43 randomized controlled trials (nine on cycling, 14 on neuromuscular electrical stimulation alone and 20 on protocolized physical rehabilitation) into which 3,548 patients were randomized and none of whom experienced an intervention-related serious adverse event. The exercise interventions had no influence on mortality (odds ratio 0.94 [0.79-1.12], n = 38 randomized controlled trials) but reduced duration of mechanical ventilation (mean difference, -1.7 d [-2.5 to -0.8 d], n = 32, length of stay in ICU (-1.2 d [-2.5 to 0.0 d], n = 32) but not at hospital (-1.6 [-4.3 to 1.2 d], n = 23). The effects on the length of mechanical ventilation and ICU stay were only significant for the protocolized physical rehabilitation subgroup and enhanced in patients with longer ICU stay and lower Acute Physiology and Chronic Health Evaluation II scores. There was no benefit of early start of the intervention. It is likely that the dose of rehabilitation delivered was much lower than dictated by the protocol in many randomized controlled trials and negative results may reflect the failure to implement the intervention. CONCLUSIONS Rehabilitation interventions in critically ill patients do not influence mortality and are safe. Protocolized physical rehabilitation significantly shortens time spent on mechanical ventilation and in ICU, but this does not consistently translate into long-term functional benefit. Stable patients with lower Acute Physiology and Chronic Health Evaluation II at admission (<20) and prone to protracted ICU stay may benefit most from rehabilitation interventions.

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20 Citations


Open accessJournal ArticleDOI: 10.1093/PTJ/PZAA115
31 Aug 2020-Physical Therapy
Abstract: Coronavirus disease 2019 (COVID-19) has sounded alarm bells throughout global health systems As of late May, 2020, over 100,000 COVID-19-related deaths were reported in the United States, which is the highest number of any country This article describes COVID-19 as the next historical turning point in the physical therapy profession's growth and development The profession has had over a 100-year tradition of responding to epidemics, including poliomyelitis; 2 world wars and geographical regions experiencing conflicts and natural disasters; and, the epidemic of noncommunicable diseases (NCDs) The evidence-based role of noninvasive interventions (nonpharmacological/nonsurgical) that hallmark physical therapist practice has emerged as being highly relevant today in addressing COVID-19 in 2 primary ways First, despite some unique features, COVID-19 presents as acute respiratory distress syndrome in its severe acute stage Acute respiratory distress syndrome is very familiar to physical therapists in intensive care units Body positioning and mobilization, prescribed based on comprehensive assessments/examinations, counter the negative sequelae of recumbency and bedrest; augment gas exchange and reduce airway closure, deconditioning, and critical illness complications; and maximize long-term functional outcomes Physical therapists have an indisputable role across the contiuum of COVID-19 care Second, over 90% of individuals who die from COVID-19 have comorbidities, most notably cardiovascular disease, hypertension, chronic lung disease, type 2 diabetes mellitus, and obesity Physical therapists need to redouble their efforts to address NCDs by assessing patients for risk factors and manifestations and institute evidence-based health education (smoking cessation, whole-food plant-based nutrition, weight control, physical activity/exercise), and/or support patients' efforts when these are managed by other professionals Effective health education is a core competency for addressing risk of death by COVID-19 as well as NCDs COVID-19 is a wake-up call to the profession, an opportunity to assert its role throughout the COVID-19 care continuum, and augment public health initiatives by reducing the impact of the current pandemic

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Topics: Health education (57%), Intensive care (56%), Public health (55%) ... read more

17 Citations


Open accessJournal ArticleDOI: 10.1016/J.PHYSIO.2021.01.007
Victoria A Goodwin1, Louise Allan1, Alison Bethel1, Alison Cowley2  +8 moreInstitutions (4)
24 Feb 2021-Physiotherapy
Abstract: Objectives To establish the evidence for rehabilitation interventions tested in populations of patients admitted to ICU and critical care with severe respiratory illness, and consider whether the evidence is generalizable to patients with COVID-19. Methods The authors undertook a rapid systematic review. Medline (via OvidSP), CINAHL Complete (via EBSCOhost), Cochrane Library, Cochrane Database of Systematic Reviews and CENTRAL (via Wiley), Epistemonikos (via Epistemonikos.org), PEDro (via pedro.org.au) and OTseeker (via otseeker.com) searched to 7 May 2020. The authors included systematic reviews, RCTs and qualitative studies involving adults with respiratory illness requiring intensive care who received rehabilitation to enhance or restore resulting physical impairments or function. Data were extracted by one author and checked by a second. TIDier was used to guide intervention descriptions. Study quality was assessed using Critical Skills Appraisal Programme (CASP) tools. Results Six thousand nine hundred and three titles and abstracts were screened; 24 systematic reviews, 11 RCTs and eight qualitative studies were included. Progressive exercise programmes, early mobilisation and multicomponent interventions delivered in ICU can improve functional independence. Nutritional supplementation in addition to rehabilitation in post-ICU hospital settings may improve performance of activities of daily living. The evidence for rehabilitation after discharge from hospital following an ICU admission is inconclusive. Those receiving rehabilitation valued it, engendering hope and confidence. Conclusions Exercise, early mobilisation and multicomponent programmes may improve recovery following ICU admission for severe respiratory illness that could be generalizable to those with COVID-19. Rehabilitation interventions can bring hope and confidence to individuals but there is a need for an individualised approach and the use of behaviour change strategies. Further research is needed in post-ICU settings and with those who have COVID-19. Registration: Open Science Framework https://osf.io/prc2y

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Topics: Cochrane Library (58%), Systematic review (58%), Intensive care (54%) ... read more

9 Citations


Open accessJournal ArticleDOI: 10.1155/2020/7840743
Abstract: Purpose. Patients admitted to the intensive care unit (ICU) are generally confined to bed leading to limited mobility that may have detrimental effects on different body systems. Early mobilization prevents or reduces these effects and improves outcomes in patients following critical illness. +e purpose of this review is to summarize different aspects of early mobilization in intensive care. Methods. Electronic databases of PubMed, Google Scholar, ScienceDirect, and Scopus were searched using a combination of keywords. Full-text articles meeting the inclusion criteria were selected. Results. Fifty-six studies on various aspects such as the effectiveness of early mobilization in various intensive care units, newer techniques in early mobilization, outcome measures for physical function in the intensive care unit, safety, and practice and barriers to early mobilization were included. Conclusion: Early mobilization is found to have positive effects on various outcomes in patients with or without mechanical ventilation. +e newer techniques can be used to facilitate early mobilization. Scoring systems—specific to the ICU—are available and should be used to quantify patients’ status at different intervals of time. Early mobilization is not commonly practiced in many countries. Various barriers to early mobilization have been identified, and different strategies can be used to overcome them.

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Topics: Intensive care (62%), Intensive care unit (52%)

8 Citations


Open accessJournal ArticleDOI: 10.1186/S12893-021-01187-2
07 Apr 2021-BMC Surgery
Abstract: Despite the unequivocal role of progressive mobilization in post-surgical patient management, its specific effects and timing, particularly after abdominal surgery, remain debated This study’s aim was to examine the short-term effects of mobilization on oxygenation in hemodynamically stable patients after open surgery for pancreatic cancer A randomized controlled clinical trial was conducted in which patients (n = 83) after open pancreatic surgery were randomized to either the same-day mobilization group (mobilized when hemodynamically stable within four hours after surgery) or the next-day mobilization group (mobilized first time in the morning of the first post-operative day) Mobilization was prescribed and modified based on hemodynamic and subjective responses with the goal of achieving maximal benefit with minimal risk Blood gas samples were taken three times the evening after surgery; and before and after mobilization on the first post-operative day Spirometry was conducted pre-operatively and on the first post-operative day Adverse events and length of stay in postoperative intensive care were also recorded With three dropouts, 80 patients participated (40 per group) All patients in the same-day mobilization group, minimally sat over the edge of the bed on the day of surgery and all patients (both groups) minimally sat over the edge of the bed the day after surgery Compared with patients in the next-day mobilization group, patients in the same-day mobilization group required lower FiO2 and had higher SaO2/FiO2 at 1800 h on the day of surgery (p < 05) On the day after surgery, FiO2, SaO2/FiO2, PaO2/FiO2, and alveolar-arterial oxygen gradient, before and after mobilization, were superior in the same-day mobilization group (p < 005) No differences were observed between groups in PCO2, pH, spirometry or length stay in postoperative intensive care Compared with patients after open pancreatic surgery in the next-day mobilization group, those in the same-day mobilization group, once hemodynamically stable, improved oxygenation to a greater extent after mobilization Our findings support prescribed progressive mobilization in patients after pancreatic surgery (when hemodynamically stable and titrated to their individual responses and safety considerations), on the same day of surgery to augment oxygenation, potentially helping to reduce complications and hasten functional recovery Trial registration: This prospective RCT was carried out at the Sahlgrenska University Hospital, Sweden The study was approved by the Regional Ethical Review Board in Gothenburg (Registration number: 437-17) Trial registration: “FoU in Sweden” (Research and Development in Sweden, URL: https://wwwresearchweborg/is/vgr ) id: 238701 Registered 13 December 2017 and Clinical Trials (URL:clinicaltrialsgov) NCT03466593 Registered 15 March 2018

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Topics: Intensive care (53%), Abdominal surgery (53%), Mobilization (51%) ... read more

3 Citations


References
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42 results found


Journal ArticleDOI: 10.1016/0021-9681(87)90171-8
Abstract: The objective of this study was to develop a prospectively applicable method for classifying comorbid conditions which might alter the risk of mortality for use in longitudinal studies. A weighted index that takes into account the number and the seriousness of comorbid disease was developed in a cohort of 559 medical patients. The 1-yr mortality rates for the different scores were: "0", 12% (181); "1-2", 26% (225); "3-4", 52% (71); and "greater than or equal to 5", 85% (82). The index was tested for its ability to predict risk of death from comorbid disease in the second cohort of 685 patients during a 10-yr follow-up. The percent of patients who died of comorbid disease for the different scores were: "0", 8% (588); "1", 25% (54); "2", 48% (25); "greater than or equal to 3", 59% (18). With each increased level of the comorbidity index, there were stepwise increases in the cumulative mortality attributable to comorbid disease (log rank chi 2 = 165; p less than 0.0001). In this longer follow-up, age was also a predictor of mortality (p less than 0.001). The new index performed similarly to a previous system devised by Kaplan and Feinstein. The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies. Further work in larger populations is still required to refine the approach because the number of patients with any given condition in this study was relatively small.

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Topics: Risk of mortality (53%), Prospective cohort study (53%), Comorbidity (53%) ... read more

34,129 Citations


Journal ArticleDOI: 10.1164/RCCM.2107138
Abstract: Sedative medications are widely used in intensive care unit (ICU) patients. Structured assessment of sedation and agitation is useful to titrate sedative medications and to evaluate agitated behavior, yet existing sedation scales have limitations. We measured inter-rater reliability and validity of a new 10-level (+4 “combative” to −5 “unarousable”) scale, the Richmond Agitation–Sedation Scale (RASS), in two phases. In phase 1, we demonstrated excellent (r = 0.956, lower 90% confidence limit = 0.948; κ = 0.73, 95% confidence interval = 0.71, 0.75) inter-rater reliability among five investigators (two physicians, two nurses, and one pharmacist) in adult ICU patient encounters (n = 192). Robust inter-rater reliability (r = 0.922–0.983) (κ = 0.64–0.82) was demonstrated for patients from medical, surgical, cardiac surgery, coronary, and neuroscience ICUs, patients with and without mechanical ventilation, and patients with and without sedative medications. In validity testing, RASS correlated highly (r = 0.93)...

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2,361 Citations


Journal ArticleDOI: 10.1016/S0140-6736(09)60658-9
30 May 2009-The Lancet
Abstract: Summary Background Long-term complications of critical illness include intensive care unit (ICU)-acquired weakness and neuropsychiatric disease. Immobilisation secondary to sedation might potentiate these problems. We assessed the effi cacy of combining daily interruption of sedation with physical and occupational therapy on functional outcomes in patients receiving mechanical ventilation in intensive care. Methods Sedated adults (≥18 years of age) in the ICU who had been on mechanical ventilation for less than 72 h, were expected to continue for at least 24 h, and who met criteria for baseline functional independence were eligible for enrolment in this randomised controlled trial at two university hospitals. We randomly assigned 104 patients by computer-generated, permuted block randomisation to early exercise and mobilisation (physical and occupational therapy) during periods of daily interruption of sedation (intervention; n=49) or to daily interruption of sedation with therapy as ordered by the primary care team (control; n=55). The primary endpoint—the number of patients returning to independent functional status at hospital discharge—was defi ned as the ability to perform six activities of daily living and the ability to walk independently. Therapists who undertook patient assessments were blinded to treatment assignment. Secondary endpoints included duration of delirium and ventilator-free days during the fi rst 28 days of hospital stay . Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00322010. Findings All 104 patients were included in the analysis. Return to independent functional status at hospital discharge occurred in 29 (59%) patients in the intervention group compared with 19 (35%) patients in the control group (p=0·02; odds ratio 2·7 [95% CI 1·2–6·1]). Patients in the intervention group had shorter duration of delirium (median 2·0 days, IQR 0·0–6·0 vs 4·0 days, 2·0–8·0; p=0·02), and more ventilator-free days (23·5 days, 7·4–25·6 vs 21·1 days, 0·0–23·8; p=0·05) during the 28-day follow-up period than did controls. There was one serious adverse event in 498 therapy sessions (desaturation less than 80%). Discontinuation of therapy as a result of patient instability occurred in 19 (4%) of all sessions, most commonly for perceived patient-ventilator asynchrony. Interpretation A strategy for whole-body rehabilitation—consisting of interruption of sedation and physical and occupational therapy in the earliest days of critical illness—was safe and well tolerated, and resulted in better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days compared with standard care.

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Topics: Intensive care (57%), Post-intensive care syndrome (55%), Sedation (54%) ... read more

2,177 Citations


Journal ArticleDOI: 10.1056/NEJMOA1011802
Abstract: Background There have been few detailed, in-person interviews and examinations to obtain follow-up data on 5-year outcomes among survivors of the acute respiratory distress syndrome (ARDS). Methods We evaluated 109 survivors of ARDS at 3, 6, and 12 months and at 2, 3, 4, and 5 years after discharge from the intensive care unit. At each visit, patients were interviewed and examined; underwent pulmonary-function tests, the 6-minute walk test, resting and exercise oximetry, chest imaging, and a quality-of-life evaluation; and reported their use of health care services. Results At 5 years, the median 6-minute walk distance was 436 m (76% of predicted distance) and the Physical Component Score on the Medical Outcomes Study 36-Item Short-Form Health Survey was 41 (mean norm score matched for age and sex, 50). With respect to this score, younger patients had a greater rate of recovery than older patients, but neither group returned to normal predicted levels of physical function at 5 years. Pulmonary function wa...

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Topics: Post-intensive care syndrome (53%), Pulmonary function testing (52%), Intensive care unit (52%) ... read more

1,657 Citations


Journal ArticleDOI: 10.1016/0895-4356(89)90065-6
Surya Shah1, Frank Vanclay1, Betty Cooper1Institutions (1)
Abstract: The Barthel Index is considered to be the best of the ADL measurement scales. However, there are some scales that are more sensitive to small changes in functional independence than the Barthel Index. The sensitivity of the Barthel Index can be improved by expanding the number of categories used to record improvement in each ADL function. Suggested changes to the scoring of the Barthel Index, and guidelines for determining the level of independence are presented. These modifications and guidelines were applied in the assessment of 258 first stroke patients referred for inpatient comprehensive rehabilitation in Brisbane, Australia during 1984 calendar year. The modified scoring of the Barthel Index achieved greater sensitivity and improved reliability than the original version, without causing additional difficulty or affecting the implementation time. The internal consistency reliability coefficient for the modified scoring of the Barthel Index was 0.90, compared to 0.87 for the original scoring.

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1,652 Citations