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Early rehabilitation in the ICU:

Beatrix Clerckx, PT

Department of Rehabilitation Sciences, Department of Intensive Care Medicine, University Hospitals Leuven,

KU Leuven Belgium

MOVE IT or LOSE IT

Truong Crit.Care 2009;13(4):216

(Pathophysiological mechanisms)

= ICUAW

Weaning failure

Emotional functioning

Deconditioning, Inactivity

+++ Sarcopenia: Low muscle mass, muscle strength, physical

performance

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Hermans et al. AJRCCM 2014

WEANING  DISCHARGE ICU DISCHARGE HOSPITAL

ICUAW and clinical outcome

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ICUAW and survival

Hermans et al. AJRCCM 2014

Prolonged ICU stay often results in long term functional and cognitive impairment (5Y)

Herridge et al. NEJM 2011

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CHEST/144/3/SEPTEMBER 2013

Reck MOTOmed Movement Therapy Systems, Germany

Cycle programme(passive/active) 20’ per dayin addition to ‘Usual’ care

‘Usual’ care: respiratory physiotherapy mobilisation

Critically ill patient• 5 days ICU and forecastof another 7 days at the ICU

Burtin et al. CCM 2009; 37:2499-2505

Studie design

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TR CO TR CO1.0

1.5

2.0

2.5

3.0

ICU discharge hospital discharge

QF

(N

/kg

)

p < 0.01p < 0.05

Burtin C, CCM 2009

TR CO

0

100

200

300

400

500

600

p < 0.05

6MW

D (

m)

TR CO

10

15

20

25

30 p < 0.05

SF

-36

PF

sco

re (

10-3

0)

196 [126-329] m 143 [37-226] m

21 [18-23] points 15 [14-23] points

‘In general, the achieved absolute workload during cycling exercise wasvery low and HR, blood pressure, andrespiratory rate did not change’.

‘In general, the achieved absolute workload during cycling exercise was?:

A: very low B: very high

Frequently researched in highly specialized (university) centers

The feasibility and safety of early physical therapy in ICU patients

Nevertheless there are still perceived ‘barriers’ to facilitate rehabilitation on the ICU

Bourdin et al. Respir. Care 2010: 55:400

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Passive / active cycling

Is het mogelijk om met een gesedeerde patiënt te fietsen?A: Ja B: Nee

• Other material (‘Be creative’)• Team Work• Change in mentality (worldwide)• Mobility protocols

Solutions for barriers

Last decade > development of different mobility protocols(Morris et al. 2008, Schweickert et al. 2009)

> The proposition of the protocol is discussed, adapted and evaluated by multidisciplinary team members

UZ LEUVEN ‘Start to move asap’ protocol

UZ LEUVEN ‘start to move’ ASAP protocol (+/-2009)

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6-level program

deliver daily mobility or physical activity from day 2after admission to the ICU

each level is determined by assessment using objective measurements

each level consists of a variety of body positionsand modalities for physical training and early mobility

Is feeding another ‘barrier’ ?

What about underfeeding or overfeeding havingdeliterious consequences for critically ill patients?

Are combined, nutrition and exercise interventions, potential strategies to prevent or

attenuate ICUAW and associated functional impairments?

How can we optimize objectively the benefits of exercise efforts in ICU- critical ill patients?

Energy expenditure in the critically ill performing early physical therapy

• REE (resting energy expenditure) determination is of high relevance to avoid both overfeeding and underfeeding

• Patients are mobilized early

• No Recommendations exists to improve nutrition when early mobilization is performed

Hickmann C.E. et all Intensive Care Med (2014)40:548-555

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Methods

prospective observational study

- 49 hemodynamically stable critically ill patients

- 15 healthy volunteers

Indirect Calorimetry (V02, VC02)

Hickmann C.E. et all Intensive Care Med (2014)40:548-555

Rest Exercise at 0,3 or 6 Watt Rest

15min 30min 15min

Results: Energy Expenditure X Exercise

Hickmann C.E. et all Intensive Care Med (2014)40:548-555

Blood lactate was not modified. Blood lactate was A: yes B: notmodified?

• The critically ill have increased REE according to inflammation defined by CRP (C-reactive protein).

• Increased energy requirement for physical activity was only present for active exercise and seems to differ with healthy population.

• For the exercise duration and intensity tested, nutritional adjustment is not indicated (the total amount of consumed calories was limited).

• The impact of prolonged active mobilization should be further investigated.

Conclusions (Hickmann)

Hickmann C.E. et all Intensive Care Med (2014)40:548-555

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Casus

Initialen: DMGeslacht: vrouwLeeftijd: 77 jaarBMI: 17kg/m214-22/8/’17: opname omv respiratoire klachten te Mol23/8/’17: transfer naar UZLEUVEN GasthuisbergAantal ligdagen ITE: 45 Diagnose: mitralisklepplastie ikv endocarditisComplicaties: cardiogene shock, pneumonie

Casus

RELEVANTE MEDISCHE VOORGESCHIEDENIS:

- diabetes mellitus- alzheimer dementie- osteoporose- cachexie- sarcopenia?

Casus

Alfonso J. Cruz-Jentoft et all,Age Ageing. 2010 Jul; 39(4): 412–423.

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Casus

VALLEN:

- Aantal valincidenten afgelopen 12 maanden: 0- Gekende valproblematiek: Neen- Valangst: een beetje- Veilig schoeisel: neen (open schoeisel met hak)- Duizeligheid of draaierigheid: neen

Casus

ACTIVITEITEN VAN HET DAGELIJKS LEVEN: (ADL,KATZ-schaal)

* Wassen en kleden volledige hulp nodig*Transfer en verplaatsen: volledig zelfstandig, zonderloophulpmiddel (rollator die ze wel heeft)

* Toiletbezoek (verplaatsen, kleden, reinigen): zelfstandig* Continentie: continent* Eten: zelfstandig

Casus

BESLUIT:

Op basis van het geriatrisch assessment werden volgende geriatrische noden bij de patiënt bepaald:- Risico op functionele achteruitgang

* Ergo-evaluatie: zelfredzaam* Kiné in te schakelen ikv bepalen nood LHM

- Aanwezigheid cognitieve beperking* Pt gekend met Alzheimer* Opvolging te Mol

- Aanwezigheid mogelijks problematische thuissituatie* Sociale dienst in te schakelen

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Casus

HUIDIGE STATUS(07/10/’17):

Neurologisch: wakker, S5Q: 4/5, delier?Hemodynamisch: stabiel, mits pacemaker Nefro: AKI in recuperatieEMG: CIPMP (ICUAW)Tracheotomie op 15/09/2017

Respiratory assessment and training:

• Tracheakap / PSV

• MIP/Pimax• (max.insp.pressure):

45% (normal value)

*Marini J.J., et al. J Crit Care 1986; 1: 32-38

Tapered flow resistive loading(POWERbreathe KH1)

• 4 sets of 6-10 breaths

• 7 days/week

• 30-50%MIP • 4-6 Borg Score – effort

and dyspnea

Inspiratory muscle training:

15cmH20

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Assessment: UZLeuven ‘Start to Move’ ASAP protocol

UZLEUVEN ‘START TO MOVE’ ASAP (from day 2 with an expected prolonged ICU stay of 5 more days) 

LEVEL 0

VARIABLE COOP.S5Q1 = 0-5

NO COOPERATIONS5Q1 = 0-5

VARIABLE COOP.S5Q1 = 0-5

CLOSE-FULL COOP.S5Q1 ≥ 4/5

FULL COOP.S5Q1 = 5

FULL COOP.S5Q1 = 5

LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5

FAILS BASIC ASSESSMENT2

PASSES BASIC ASSESSMENT3

PASSES BASIC ASSESSMENT3

PASSES BASIC ASSESSMENT3

PASSES BASIC ASSESSMENT3

PASSES BASIC ASSESSMENT3

TRANSFER to chairnot allowed becauseof neurological orsurgical or trauma condition

ACTIVE TRANSFER to chair not allowedbecause of obesityor neurological orsurgical or trauma condition

MRCsum ≥ 36(MRCsumLL≥ 18)BBS Sit to stand = 0BBS Standing = 0BBS Sitting ≥ 1

MRCsum ≥ 48(MRCsumLL≥ 24)BBS Sit to stand ≥ 0BBS Standing ≥ 0BBS Sitting ≥ 2

MRCsum ≥ 48BBS Sit to stand ≥ 1BBS Standing ≥ 2BBS Sitting ≥ 3

BODY POSITIONING4

°2h turning°Splinting°Positioning

BODY POSIT.4

°2h turning°Splinting°Upright sittingposition in bed

°Passive transfer bed to chair

BODY POSIT.4

°2h turning°Passive transfer bed to chair

°Sitting out of bed°Standing withassist (≥ 2 pers)

BODY POSIT.4

°2h turning°Splinting°Fowler’s position

BODY POSIT.4

°Active transfer bed to chair

°Sitting out of bed°Standing withassist (≥ 1 pers)

BODY POSIT.4

°Active transfer bed to chair

°Sitting out of bed°Standing

PHYSIOTHERAPY°No treatment

PHYSIOTHER.4

°Passive/active ROM°Passive/active leg and/or arm cyclingin bed°NMES°ADL

PHYSIOTHER.4

°Passive/active ROM°Resistance training arms and legs

°Passive/active leg and/or arm cyclingin bed or chair

°NMES°ADL

PHYSIOTHER.4

°Passive/active ROM°Resistance training arms and legs

°Active leg and/orarm cycling in bed or chair

°Standing (withassistance/frame) °NMES°ADL

PHYSIOTHER.4

°Passive/active ROM°Resistance training arms and legs

°Active leg and/orarm cycling in bedor chair

°Walking (withassistance/frame)

°NMES°ADL

CLINICAL  IN

VESTIGATION

REH

ABILITATION

INTENSIEVE GENEESKUNDE

MULITD

ISCIPLINARY APPROACH

PHYSIOTHER.4

°Passive/active ROM°Resistance training arms and legs

°Active leg and/orarm cycling in bedor chair

°Walking (withassistance)

°NMES°ADL

ADEQUACY SCOREA. Open and close your eyesB. Look at meC. Open your mouth and put out your tongueD. Nod your headE. Raise your eyebrows when I have counted

up to five

BERG BALANCE SCORESITTING TO STANDING4 able to stand without using hands and

stabilize independently3 able to stand independtly using hands2 able to stand using hands after several tries1 needs minimal aid to stand or stabilize0 needs moderate or maximal assist to stand

Right Reason EP Left Reason EP

MS: Abduction of the arm

MS: Flexion of the forearm

MS: Extension of the wrist

MS: Flexion of the leg

MS: Extension of the knee

MS: Dorsal flexion of the foot

STRENGTH SUBTOTAL VALUE STRENGTH TOTAL=

EP SUBTOTAL VALUE EP TOTAL         =

MRC TOTAL SUMSCORE

MRC-SCALE0 = no visible contraction1 = visible contraction without movements of the limbs2 = movements of the limbs but not against gravity3 = movement against gravity over (almost) the full range4 = movement against gravity and resistance5 = normal

MRC-SUMSCORE Pre-existing NMD: □ No □ Yes:______________

Dominantie:

STANDING UNSUPPORTED4 able to stand safely for 2 minutes3 able to stand 2 minutes with supervision2 able to stand 30 secondes unsupported1 needs several tries to stand 30 secondes

unsupported0 unable to stand 30 secondes unsupported

SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL4 able to sit safely and securely for 2 minutes3 able to sit 2 minutes under supervision2 able to sit 30 seconds1 able to sit 10 seconds0 unable to sit 10 seconds unsupported

1: score 5 questions: adequate response to 5 standardized orders

2: FAILS = at least 1 risk factor present3: if basic assessment failed, decrease to level 04: safety and feasibility: each activity should be

deferred if severe adverse events (cv., resp., internal and subject. intolerance) occur duringthe intervention

BASIC ASSESSMENT =-Cardiorespiratory unstable

* MAP < 60mmHg or* FiO2 > 60% or* PaO2/Fi02 < 200 or* RR > 30 bpm

-Neurologically unstable-Acute surgery-Temp > 40°C

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SCORE 5 QUESTIONS2

A. Open and close your eyes □

B. Look at me □

C. Open your mouth and put out your tongue □

D. Nod your head □

E. Raise your eyebrows when I have counted up to five □

De Jonghe B., et al. Crit Care Med 2007; 35(9): 2007-14.

Adequacy score

‐ Cardiorespiratory unstable* MAP < 60mmHg or* FiO2  > 60% or* PaO2/Fi02 < 200 or* RR > 30 bpm

‐ Neurologically unstable

‐ Acute surgery

‐ Temp > 40°C

Basic assessment

0 = No visible contraction

1 = Visible contraction without movements of the limbs

2 = Movements of the limbs but not against the gravity

3 = Movement against gravity over (almost) the full range

4 = Movement against gravity and resistance

5 = Normal

Kleyweg R.P., et al. Muscle Nerve 1991; 14(II): 1003‐09. 

MRC‐scale:  0‐5  score

Functional assessment

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Score < 48/60:‘significantmuscle weakness’

De Jonghe B, JAMA 2002

MRC total sumscore: 38/60

Berg Balance score ‘Start to move asap’ protocolBerg Balance score

SITTING TO STANDING4 able to stand without using hands and stabilize independently3 able to stand independently using hands2 able to stand using hands after several tries1 needs minimal aid to stand or stabilize0 needs moderate or maximal assist to stand

STANDING UNSUPPORTED4 able to stand safely for 2 minutes3 able to stand 2 minutes with supervision2 able to stand 30 seconds unsupported1 needs several tries to stand 30 seconds unsupported0 unable to stand 30 seconds unsupported

SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL4 able to sit safely and securely for 2 minutes3 able to sit 2 minutes under supervision2 able to able to sit 30 seconds1 able to sit 10 seconds0 unable to sit without support 10 seconds

Handgrip force (JAMAR®)

Handheld dynamometry, handgrip strength:

Isometric muscle testing (MicroFet®)

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Handgrip force (JAMAR®)

handgrip strength: 25% (normal value)

Enteral feeding: (swallowing disorder)

LEVEL 0 LEVEL 5LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4

UZLEUVEN ‘START TO MOVE' ASAP

CLOSE TO FULLCOOPERATION

S5Q1 ≥ 4/5

PASSES BASIC ASSESSMENT3 +

MRCsum ≥ 36 +

BBS² Sit to stand = 0 +

BBS² Standing = 0 +

BBS² Sitting ≥ 1

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BODY POSITIONING

2hr turning

Passive transfer bed to chair

Sitting out of bed

Standing with assist (2 ≥ pers)

Jointly with nursing staff

LEVEL 0 LEVEL 5LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4

UZLEUVEN ‘START TO MOVE' ASAP

CLOSE TO FULLCOOPERATION

S5Q1 ≥ 4/5

PASSES BASIC ASSESSMENT3 +

MRCsum ≥ 36 +

BBS² Sit to stand = 0 +

BBS² Standing = 0 +

BBS² Sitting ≥ 1

BODY POSITIONING4

2hr turning

Passive transfer bed to chair

Sitting out of bed

Standing with assist (2 ≥ pers)

PHYSIOTHERAPY:

Passive/Active  range of motion

Resistance training arms and legs

Active leg and/or arm cycling in chairor bed

Walking (with assistance/frame)

NMES

ADL

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NMES:

PHYSIO in combination FEEDING

Walking > adjustment Insuline (discontinuation feeding)

ADL > functional > eating, drinking

Logopedy > swallowing disorders for eating

LEVEL 0 LEVEL 5LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4

UZLEUVEN ‘START TO MOVE' ASAP

CLOSE TO FULLCOOPERATION

S5Q1 ≥ 4/5

PASSES BASIC ASSESSMENT3 +

MRCsum ≥ 36 +

BBS² Sit to stand = 0 +

BBS² Standing = 0 +

BBS² Sitting ≥ 1

BODY POSITIONING4

2hr turning

Passive transfer bed to chair

Sitting out of bed

Standing with assist (2 ≥ pers)

PHYSIOTHERAPY4

Passive/Active range of motion

Resistance training arms and legs

Active leg and/or arm cycling in bed or chair

NMES

ADL

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Conclusions I

Critical Illness is associated with short and long term morbidity (functional status, quality of life)

There is a variety of exercise modalities available for early stages of critical illness that facilitate functional

outcome

Conclusions II

The role of physiotherapy and rehabilitation in early prevention and treatment of deconditioning during and

after critical illness need much more attention

Research should be conducted to further establish the effectiveness of exercise modalities in patients with critical illness on muscle function, QOL and physical

function

Conclusions III

Treatment should be administered jointly between medical, physical therapy and

nursing staff.

The physical therapist should be responsible for implementing mobilization plans and exercise prescription and make

recommendations for progression of these in conjunction with other team

members.

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ICU Physical Therapy Team

THANK YOU!

Questions?