INTRODUCTION
Immobilization affects the musculoskeletal, gas- safe and feasible, and can be either passive or active,
trointestinal, urinary, cardiovascular, respiratory and according to the patient’s interaction, hemodynamic
skin systems. (7) Disuse, such as during rest, inactiv- stability, ventilatory support level, inspired oxygen
ity or limbs or body immobilization and nervous fraction (FiO 2) and response to therapy. (11,15,20,21)
losses in diseases or injuries promote muscle mass, Physical training in an ICU is a logical rehabili-
strength and endurance decline. With total immobi- tation extension, and has been shown a key critical
lization, muscle mass may be reduced by one half in care component. (13) Exercises offer well-established
less than two weeks, and when associated with sepsis, physical and psychological benefits, and additionally
decline daily up to 1.5 kg. (7,8) Experimental trials in reduce the oxidative stress and inflammation, due to
healthy subjects showed weekly up to 4% - 5% mus- increased anti-inflammatory cytokines production. (6)
cle strength loss. (9) In cases with destroyed nerve to Previous studies have shown that in most times, after
muscle connection, muscle atrophy is even faster. (7) discharge from the hospital, patients with reduced
The connection between hypoglycemia and weakness body function will need a training schedule. (22)
may be related to its toxic effects, which is counter- This study aims to review the publications on ki-
acted by the neuro-protective and anti-inflammatory nesiotherapy and its effects in ICU staying patients,
insulin effects. (10) analyzing the methodologies and their results in ICU
All these factors associated contribute for pro- immobilized subjects.
longing the ICU stay, result in increased risks of
complication, mortality and costs. (2,11-15) Emotional METHODS
disorders such as anxiety and depression increase the
hospital stay, physical deficits, and may affect the The literature research was performed in the elec-
function and consequently the one to seven years af- tronic databases MedLine, LILACS, CINAHL, Co-
ter the event patient’s quality of life, entailing social chrane, High Wire Press and SciELO, for the period
impairment. (13,14,16) between January 1998 and July 2009.
Early intervention is required to prevent both The key works used, in different combinations,
physical and psychological issues. Therapeutic activ- were: “critical illness”, “cinesiotherapy”, “physi-
ity should be started early to prevent prolonged hos- cal therapy”, “physiotherapy”, “exercises”, “train-
pitalization and associated immobilization risks, (17) ing”, “force”, “active mobilization”, “mobiliza-
and may be one of the keys for patient’s recovery. (14) tion”, “ICU”, “rehabilitation”, “mobility”, “muscle
The critically ill ICU patient bears severe motor strength” and “weakness”.
restrictions. The appropriate positioning in bed and The search was limited to English, Spanish and
early mobilization may mean unique opportunities Portuguese languages, with studies in 19 years or
for the subject’s interaction with the environment, older adult humans, and published in the last 10
and should be considered as sensorial-motor stimu- years. Academic publications abstracts were not in-
lation sources, and prevention of complications sec- cluded.
ondary to immobilization. (11,14,17) The titles and abstracts were analyzed to identify
There are few studies approaching the role of ki- articles potentially relevant for the review.
nesiotherapy role in critically ill patients, initially
seen as “too ill” or “too clinically unstable” for mo- RESULTS
bilization interventions. (18) Nevertheless, therapeutic
exertion show benefits, specially when started early, Ten studies considered relevant for the review
although approaches diversity. (15) Postponing start of were identified. These are chronologically shown in
exercises only worsens the patient’s disability. (18) Chart 1.
After discharge from the ICU, the patients have Martin et al. (23) evaluated in a retrospective analy-
disabilities lasting for up to one year, being unable to sis the weakness prevalence and magnitude in pro-
go back work due to persistent fatigue, weakness and longed mechanic ventilation patients, and the im-
poor functional status. (19) Rehabilitation has a poten- pact of a rehabilitation schedule on the variables
tial to restore functional status, but sometimes is only weaning, muscle strength and functional status. This
started after discharge from the unit, that is, too late. schedule included trunk control, passive, active, ac-
(11)
Early ICU kinesiotherapy has been shown to be tive-resisted, with thera-band and weight exercises,
Chart 1 - Continuation
Author/Year Type of study Sample Intervention Main analyzed variables Relevant results
Morris et al. Prospective Various diagno- 4 levels protocol. Passive Number of days stay (ICU Reduction of hospital
(2008)(15) cohort sis patients, 3 movements, active-assisted and hospital), hospital days, reduced hospital
days from admis- and active (functional chal- costs, number of days for costs, and less days for
sion and at least lenge without weights), leaving bed for the first the leaving bed for the
48 hours IOT, seating on bed, seating time. first time in the inter-
n=165 (con- balance, weight discharge vention group.
trol group) and standing, transference from
n=165 (interven- bed to chair (vice-versa)
tion group) and walking
Needham Case report One severe Early walking, from 4th Sedation level, early mo- Improved self-esteem,
(2008)(9) COPD patient TOT day (patient under bilization and walking by and self perceived func-
MV) for 6 weeks physiotherapy at ICU and tion status
quality of life after dis-
charge
Burtin et al. Randomized, Various diagno- Respiratory physiotherapy, TC6 and SF-36 (by hos- Increased quadriceps
(2009)(27) controlled sis patients, ICU passive or active mobiliza- pital discharge), palmar strength, improved
stay expected tion for lower and upper grip, isometric quadriceps function and self-per-
for 7 or more limbs, both groups. In the strength (portable dyna- ceived function status in
days, n=45 (con- treatment group, additio- mometer), functional sta- the treated group.
trol group) and nally cycloergometer for tus (Berg scale), weaning
n=45 (treatment the lower limbs|inferiors. time, ICU and hospital
group) stay time, and mortality at
1 year after discharge
COPD – chronic obstructive pulmonary disease; TC6 – 6 minutes walk test; VAS – visual analogic score; FES – functional electrical stimulation;
MV – mechanic ventilation; TMR – respiratory muscle training; FIM – functional independence measurement score; SpO2 – peripheral oxygen
saturation; PSV – pressure suport ventilation; TOT – orotracheal tube ; ICU – intensive care unit; SF-36 - Quality of life inventory.
sistance, versus 70% in the control group, being that cluded that this variable was similar for both groups.
by the entry time, all were restricted to bed. Other variables as respiratory rate, peripheral oxygen
Morris et al. (15) in a prospective cohort study of saturation (SpO 2), tidal volume, heart rate, intrinsic
a kinesiotherapic exercises protocol, among others positive end-expiratory pressure, had better values
aimed to compare a group of protocol subjects to with PSF.
a usual care control group. This consisted of pas- Burtin et al. (27) investigated if daily exercise ses-
sive bed movements and decubitus changes every sions with lower limbs cycloergometer, still on bet,
two hours. The protocol was divided in four levels. would be safe and effective for prevention or attenu-
Level I was conducted on the still unconscious pa- ation of exercise performance, functional status and
tient, passively moving all joints but shoulder and quadriceps strength. The control group therapy con-
hip extension, restricted by the position. On Level sisted of respiratory physiotherapy and upper and
II, where the patients were already able to respond to lower limber active or passive movements, depending
verbal orders, in addition to the passive movements, on the patient’s sedation degree, five times weekly.
active-assisted, active or active-resisted movements Walking was started as soon as deemed safe and ap-
were performed, according to the strength degree, propriate. The treatment group received, addition-
and also seating in the bed. On Level III, the exer- ally, daily 20 minutes long exercises sessions with in-
cises aimed to strength the upper limbs, and were creasing resistance levels. Sedated patients had fixed
performed with the patient seating by the bed side. 20 cycles/minute frequency, while those able to help
Weights use was not included in the protocol, be- had their sessions divided in two 10 minutes times,
ing added functional challenges according to the de- plus intervals when needed. Each session the training
velopment. On the fourth level, were trained trans- intensity was evaluated and resistance increase tried,
ference from bed to chair (and vice-versa), seating according to the patient’s toleration. A statistically
balance activities, weight discharge with the patient significant improvement was seen in treatment ver-
standing, and walking. No intercurrence was seen sus control groups respecting the evaluated variables,
during the protocol implementation, being it rated i.e., increase of function recovery, increased quad-
as safe and effective. The intervention group had riceps strength, and improved self-perceived func-
gains regarding the number of days to the first time tional status. Independent walking was higher in the
leaving bed, hospitalization days and hospital costs. treatment group.
Two of the studies, Porta et al. (25) and Vitacca et Zanotti et al. (28) compared the effects of active
al., (26) used an upper limbs cycloergometer for car- lower limbs mobilization with and without Func-
dio-respiratory ability evaluation and treatment. The tional Electrical Stimulation (FES) in 24 COPD
incremental test, which is symptom-limited, i.e., ad- subjects with severe peripheral muscle atrophy then
dition of a load per minute and the patient lead to ex- depending on mechanic ventilation. The program
haustion, only stopped before this threshold if heart was four weeks long, and was performed five times
rate reached the limit, or electrocardiogram changes weekly. The muscle strength significantly improved
were seen. The endurance test was performed with in both groups versus baseline. Regarding the num-
50% of the peak load reached in the incremental ber of days for transference from bed to chair, there
test, and was also ended with patient-reported ex- was a statistically significant improvement in the
haustion. FES group. The intervention group took in average
In the Porta et al. (25) study, the upper limbs cy- 10 days to transfer, while the control group an aver-
cloergometer was added to kinesiotherapy in the in- aged 14 days.
tervention group for 20 minutes daily for 15 days Bailey et al., (21) in a prospective cohort study
, with 2.5 W/day increases/reductions according to evaluated the feasibility and safety of early activities
the modified Borg scale and rest pause. The inter- in subjects mechanically ventilated for more than 4
vention group had a significant improvement versus days. The activities were developed twice daily, and
the control group. Vitacca et al. (26) evaluated the ef- included seating by the bed side without support,
fects of cycloergometer in the upper limbs in with seating on chair after transferring from the bed, and
and without pressure support ventilation (PSV) pa- walking without or with a person or walker assis-
tients, also using the modified Borg scale to quantify tance. The activities aimed the patient walking more
the dyspnea and upper limbs discomfort, and con- than 100 feet (3048 cm) before discharged from the
unit; 2.4% of the subjects had no activity until the ter standardization for appropriate description and
discharge, 4.7% seated by the bed side, 15.3% seated comparison of different treatment protocols.
on a chair, 8.2% walked less than 100 feet (3048 cm)
and 69.4% walked more than 100 feet (3048 cm). It ACKNOWLEDGMENTS
was defined as early the therapy started when the pa-
tient was hemodynamically stable, with no amines, We thank all colleagues and preceptors at Hospi-
FiO 2 ≤ 60% and PEEP ≤ 10 cmH 2O need, able to re- tal Universitário Pedro Ernesto for the incentive to
spond to verbal stimulation according to neurologi- their residents’ technique-scientific growth.
cal evaluation criteria. No activity was started during
coma and/or less than 4 days in mechanic ventilation
patients, justifying that patients needing longer than RESUMO
4 days mechanic ventilation are more endangered of
physical weakness. O desenvolvimento de fraqueza generalizada relacio-
One case report was recently published by Need- nada ao paciente crítico é uma complicação recorrente
em pacientes admitidos em uma unidade de terapia in-
ham,(9) where a patient with severe COPD, 56 years-
tensiva. A redução da força muscular aumenta o tempo de
old, acute renal failure, walked on the 4th day following
desmame, internação, o risco de infecções e conseqüente-
ICU admission, with orotracheal tube and mechanic mente morbimortalidade. A fisioterapia é usada nesses pa-
ventilation installed. The patient walked a total of 140 cientes como recurso para prevenção da fraqueza muscular,
meters divided in three phases, assisted by a walker hipotrofia e recuperação da capacidade funcional. O obje-
and two physiotherapists constantly monitoring heart tivo deste estudo foi rever a literatura relacionada ao uso
rate, blood pressure, electrocardiographic track and da cinesioterapia em pacientes internados em unidades de
oxygen saturation. In an interview the patient Mr. E. terapia intensiva. A pesquisa da literatura foi realizada por
showed improved self-esteem, and self-perceived mus- meio das bases eletrônicas de dados MedLine, LILACS,
cle strength and functional status. Also reported that CINAHL, Cochrane, High Wire Press e SciELO, de ja-
it was not uncomfortable to walk with a tube in his neiro de 1998 a julho de 2009 e capítulos de livros uti-
mouth, and that this benefited his recovery. lizando palavras-chave incluindo: “critical illness”, “cine-
siotherapy”, “physical therapy”, “physiotherapy”, “exercises”,
“training”, “force”, “active mobilization”, “mobilization”,
CONCLUSION
“ICU”, “rehabilitation”, “mobility”, “muscle strength” e
“weakness”. Apesar da escassez de estudos e da diversidade
Kinesiotherapy, including early started, appears metodológica dos estudos encontrados demonstrando o
to bring favorable results for muscle weakness rever- uso da cinesioterapia como recurso terapêutico, o seu uso,
sion in critically ill patients, providing faster return inclusive precocemente parece uma alternativa à preven-
to function, reduced weaning time and hospitaliza- ção e reversão da fraqueza muscular adquirida na unidade
tion. Although the evaluated studies suggest its use de terapia intensiva.
to be safe and effective, their methodological diver-
sity points to the need of further randomized and Descritores: Cinesioterapia; Modalidades de terapia
controlled studies, with larger cases series and bet- física; Debilidade muscular/reabilitação