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Exercise intervention in the critical care unit what is the evidence?

Amanda J. Thomas
Physiotherapy Department, The Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK Objectives: Physical morbidity is a well documented phenomenon of the patient confined to bed with critical illness and may persist for months following the critical care stay. Early rehabilitation activities initiated during the critical care stay may ameliorate these changes and reduce the long term burden of care associated with a critical care admission. The objective of this review is to explore the known evidence examining the issue of rehabilitation of the patient with critical illness. Methods: Database searches were performed to retrieve the search terms mobilisation, rehabilitation, exercise therapy, physiotherapy, ambulation, muscle strength, functional training, mechanical ventilation, intensive care, and critical care. Results: Physiotherapy practice varies widely throughout Europe, North America and Australasia and rehabilitation interventions for critically ill patients have received little research attention. Retrieved data was reviewed in the following categories: a) The incidence of rehabilitation practices within intensive care units, b) Safety issues associated with exercising the critically ill patient, c) The acute response to exercise in the critically ill, and d) The effects of physical training programmes in ventilator dependent subjects. Discussion: Evidence of the effectiveness of physical training within the intensive care environment remains limited to long term respiratory failure patients who may not be representative of a general critically ill population. Preliminary data from protocol initiated physiotherapy intervention initiated within 48 h of the onset of mechanical ventilation in medical patients reveal both decreased intensive care unit and hospital length of stay. It is clear that research funding should be allocated to strengthen physiotherapeutic practice in this area. In particular the relationship between muscle strength, functional scales and other measures of outcome including number of days to wean from mechanical ventilation and length of stay need to be explored.
Keywords: Critical care, physiotherapy, rehabilitation, exercise training, functional ability, mechanical ventilation.

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Introduction
It is widely recognized that improvements in critical care management over the last twenty years have increased the number of patients surviving an intensive care admission.1 Strong evidence exists to highlight the prolonged dependency of these survivors, and the need for physical rehabilitation programmes in the post intensive care period.24 For example, eight weeks
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following discharge from an intensive care unit in the United Kingdom, 12% of survivors continued to use a mobility aid indoors, 44% were unable to manage stairs and 29% were wheelchair dependent outside the home.2 In addition, intensive care survivors subjectively report exhaustion, weakness, poor balance and fear of falling in the period following discharge from the intensive care unit.3,4

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Ethical restrictions have not enabled a full appreciation of the physical adaptations that occur as a result of critical illness and the concomitant decline in mobility experienced by these populations. Apart from what is known and extrapolated from research in healthy male volunteers assigned to periods of bed rest, data is now emerging that reects the signicant physical limitations of a critical care population. For example, in a group of patients dependent upon mechanical ventilation, the shoulder exor, elbow exor and knee extensor strength was reported as 15, 18 and 13%, respectively, of an age matched normal sample.5 Similarly, studies reporting a 5-point muscle score in ventilator dependent subjects reveal baseline muscle grades between 1 (icker of muscle contraction) and 2 (muscle moves joint with gravity eliminated).6,7 Functional scales also conrm the poor ability of these populations. Supine-to-sit and sit-tostand Functional Independence Measure (FIM) subscores equating to the total assistance of two people have been reported in some mechanical ventilated patients,6 as well as baseline FIM scores for mobility that represent only 14% of a fully independent score in others.5 These studies highlight the dramatic effects of a critical care admission on physical ability and provide ample justication for early rehabilitative techniques that minimise and/or reverse these changes. The use of rehabilitation programmes in the patient with critical illness has the potential to decrease time in critical care units, shorten overall hospital stay and prevent readmission.8 Indeed, early rehabilitation in elderly orthopaedic subjects has demonstrated reduced length of hospital stay, reduced costs and faster restoration of functional status.9 Similarly, patients with community acquired pneumonia randomised to early mobilisation (a 20 min walk on the rst day of admission) demonstrate decreased length of hospital stay.10 Unfortunately, there are few descriptions of what rehabilitation within the intensive care unit currently entails8 and research which examines the specic role of physical rehabilitative techniques
Table 1 Levels of evidence (NICE, 2001) Level Ia Ib IIa IIb III IV Type of evidence Evidence obtained Evidence obtained Evidence obtained Evidence obtained Evidence obtained case studies Evidence obtained from from from from from

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during a critical care admission is scarce.11 Norrenberg and Vincent12 point out that the role of the physiotherapist within European intensive care units varies widely depending on stafng levels and expertise. The variety of physiotherapy practice throughout Europe, North America, Australia and Asia make intercontinental comparisons difcult. In addition, research in the critical care unit is fraught with experimental control issues and it may be unethical to deny a critically ill patient the possibility of receiving some form of rehabilitation.13 Consequently, rehabilitation interventions for critically ill patients have received little research attention.14 The purpose of this review is to explore the known evidence examining the issue of rehabilitation of the patient with critical illness.

Search strategy
Database searches of MEDLINE (1966 Aug 2008), CINAHL (1982 Aug 2008), EMBASE (1988 Aug 2008), The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2006), and PEDro (1929 Aug 2008) were completed. The search terms used included mobilisation, rehabilitation, exercise therapy, physiotherapy, ambulation, muscle strength, functional training, mechanical ventilation, intensive care, and critical care. Database searches were supplemented by references from conference proceedings, personal communication and by hand searching. Literature concerned with populations who were receiving exercise training, mobilisation or rehabilitation during the intensive care unit stay was included in the review. The methodological quality of any randomised controlled trial was evaluated using the PEDro scale (Maher, 2003).15 Other studies were evaluated according to the levels of evidence suggested by the National Institute for Clinical Evidence16 (Table 1).

Results
Very few articles were retrieved by the search criteria. Further analysis of the retrieved research identied

systematic review or meta-analysis of randomised controlled trials at least one randomised controlled trial at least one well-designed controlled study without randomisation at least one other type of well-designed quasi-experimental study well-designed descriptive studies, such as comparative studies, correlation studies and

from expert committee reports or opinions and/or clinical experience of respected authorities

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several areas that could inform this review, but the quality of the research would not support systematic analysis techniques. Consequently, the retrieved research was grouped for consideration as follows:

N N N N

The incidence of rehabilitation practices within intensive care units. Safety issues associated with exercising the critically ill patient. The acute response to exercise in the critically ill. The effects of physical training programmes in ventilator dependent subjects.

lying to sitting on the bed edge, sitting to standing, a standing transfer from bed to chair, or walking) as a component of their overall physiotherapy management. In addition, rehabilitation activities represented less than 20% of the total physiotherapy activity during the study period. While it is clear that rehabilitation techniques are employed by physiotherapists within critical care settings, more data is required to characterise the extent of these practices and the populations to which they may be applied.

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One paper examined the relationship between early mobility within an intensive care unit and the eventual length of hospital stay. Commentaries regarding the importance of early rehabilitation in the intensive care unit without supportive clinical data were also used to inform this review.

Safety criteria for exercise in the critical care patient


The decision to commence rehabilitation activities in the critically ill may be guided by the use of a comprehensive screening process combined with individual multi-system assessment and analysis (level III evidence). Screening guidelines for safe mobilisation of the critically ill patient2022 and criteria for initiation of activity in intensive care patients have been published.23 These guidelines incorporate an analysis of intrinsic issues associated with the patients medical stability (cardiovascular and respiratory reserve), and external factors such as invasive monitoring, environment, equipment, staffing and consent issues.24 Guideline authors recognise that clinical practice is informed by individual assessment and that physiological parameters identied within the screening process should not be interpreted in isolation,19 but appreciated within the context of an individuals presentation and response to intervention.24 The application of one published screening process (Stiller and Phillips22) identied 19% of the intensive care population for whom exercise was thought to be safe.19 Subsequent clinical deterioration during

Incidence of rehabilitation practices in critical care environments


Several publications provide a description (level III) of rehabilitation practices within critical care units in Canada17 the United Kingdom8 and Australia.18 A summary of the results of these surveys is presented in Table 2. These papers provide an indication of the variety of rehabilitative techniques used within critical care environments, but do not indicate their frequency of use, the proportion of all physiotherapy activity that is rehabilitation related or the populations in which they are targeted. Stiller et al.19 examined the physiotherapy management of patients admitted to an Australian tertiary-referral intensive care unit over two discreet three-week periods. During the study intervals, 19.3% of the population received a rehabilitation intervention (moving from

Table 2 Rehabilitation activities reported by physiotherapists in critical care units: Percentage gure denotes percentage of respondents who reported using the intervention in their clinical practice. Canada (King and Crowe, 1998), the United Kingdom (Lewis, 2003) and Australia (Chang Boots, Hodges and Paratz 2004, and Skinner, Berney, Warrillow and Denehy 2008) King and Crowe (1998) Positioning in bed (100%) Transfer to sitting (100%) Ambulation with mechanical ventilation (56.3%) Lewis (2003) Passive movements (97%) Tilt table (86%) Hoist to chair (90%) Standing frame (59%) Musculoskeletal assessment and exercise regime (100%) Ambulatory ventilation or sitting over the edge of the bed (69%) Chang Boots, Hodges and Paratz, (2004) Sit to stand and walking on the spot (100%) Mobilising with manual assistance (98.8%) Wheeled walking frame (97.6%) Sitting out of bed and high sitting (100%) Tilt table (67.4%) Stationary Cycling (20.9%) Treadmill walking (3.5%) Skinner, Berney, Warrillow and Denehy (2008) Active Assisted/free active exercise (97%) Sit to stand (97%) Sit on edge of bed (94%) March on spot (97%) Walk away from bed (97%) Bed transfer training (67%) Tilt Table (63%)

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exercise with these patients occurred with a low incidence (4.3%) and may have been due to the application of the rigorous pre-treatment screening. Bailey and colleagues23 described the feasibility of an early activity program with mechanically ventilated respiratory failure patients in a respiratory intensive care unit. Subjects commenced an activity program based on neurological (response to verbal stimulation), respiratory (FiO2 , 0.6 and positive endexpiratory pressure , 10 cm H20) and circulatory criteria (absence of orthostatic hypotension and catecholamine drips). Using these criteria alone, most patients were able to participate in activity regardless of age, organ failure, intubation, co-morbidities or level of FiO2. The time to activity from initial intensive care unit admission was 6.6 5.5 days to sit on the edge of the bed, 8.8 7.6 days to sit in the chair, 11.3 10.1 days to walk and 12.4 10.7 days to walk further than 100 feet. Adverse events occurred in 14 of 1449 activity events (0.96%) over the period of the study. No adverse event resulted in complications requiring additional therapy, or increased length of stay. More recently, a protocol driven rehabilitation process initiated 48 h after onset of mechanical ventilation in medical patients24 was determined by the patients ability to interact with the mobility team and their muscle strength. For example, a biceps muscle strength during one effort of 3/5 (Medical Research Council scale) was required to advance from the second to third level of the mobility protocol. In this investigation, the protocol driven rehabilitation plan elicited a large percentage (80%) of patients receiving early physiotherapy intervention compared with 47% who received physiotherapy intervention following direct medical referral. It is clear that locally relevant early rehabilitation inclusion tools should be developed that allow physiotherapists to identify the earliest opportunities for participation in rehabilitation activities.

Acute physiological response to exercise


When low level exercise is utilised as a physiotherapy technique in critical care it is done to provoke an immediate cardiovascular and respiratory response.25 These short term responses represent desirable adaptations in the oxygen transport pathway26,27 and are utilised to treat a variety of underlying clinical presentations, including but not limited to decreased lung volumes and secretion retention. However, limited data exists regarding the extent of acute physiological change in response to low levels

of exercise in critically ill patients. Several papers were identied (level IIb and III) that document the rst descriptions of the acute response to low level exercise interventions with intensive care populations. Zaropoulos and collegues28 examined the respiratory and haemodynamic consequences of a functional exercise protocol in intubated abdominal surgical patients. The intervention consisted of progressing from supine lying, sitting on the bed edge, standing, walking on the spot for 1 min, sitting out of the bed initially and sitting out of bed after 20 min. In comparison to supine lying, the standing position increased minute ventilation by 41%, tidal volume by 24%, respiratory rate by 16% and heart rate by 11%. Sitting over the bed edge elevated mean arterial pressure 17% from the supine lying baseline. All variables returned to below baseline within 20 min of completion of the intervention. Chang and co-workers18 evaluated the acute effects of standing an intensive care patient on a tilt table. Compared with the supine position, passive standing increased minute ventilation by 27%, tidal volume by 17% and respiratory rate by 19%, in a mixed sample of spontaneously breathing and intubated subjects. These acute responses had fallen to below pretreatment values 20 min after cessation of tilting. Stiller et al.19 investigated the cardiovascular responses to sitting over the bed edge in 31 intensive care unit patients of whom 40% were intubated. Compared with pre-treatment values, 76.8% of subjects experienced an increase in heart rate (HR), although 17.4% experienced a fall. Similarly, 85.2% of subjects experienced an increase in systolic blood pressure (SBP) while 13.1% experienced a fall of greater than 20mmHg. The magnitude of these changes represented less than 10% change from baseline. These preliminary studies represent the rst descriptions of the acute effects of simple exercise tasks in a critically ill population. The mechanism underlying these responses has been attributed to changes in body posture from supine to upright or standing, and the subsequent anatomical or gravitational changes that occur. While gravitational effects undoubtedly contribute to any observed changes in tidal volume and minute ventilation, the metabolic consequence of these exercise interventions remains unknown. It is feasible that increases in cardiovascular and respiratory variables are due to an increase in oxygen consumption elicited by the activity. The ability to measure the metabolic requirements of these low level interventions will allow the comparison of

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effect sizes, and determination of the appropriateness of the elicited response. This may allow comparisons to be made based upon the intensity of the activity performed. Furthermore, the benet of these acute interventions to the long term outcome of the critically ill in-patient is yet to be evaluated.

Response to exercise training


Several studies have reported the effects of physical training strategies in mechanically ventilated patients. Table 3 summarises the ndings from these investigations and the outcome measures used to evaluate differences between groups. These studies were conducted within dedicated units where multidisciplinary teams treat respiratory failure patients requiring prolonged mechanical ventilation or those who have failed conventional weaning attempts.29 In all cases, subjects were bed bound and ventilator dependent at the start of the study. However, these investigations are difcult to compare since the intensity, frequency and duration of exercise interventions is variable between and within each study. Other than the report by Chiang and colleagues,5 full descriptions of the exercise interventions are not generally provided. Similarly, it remains unknown whether the changes described below would be the same within a non respiratory failure critical care population. It is also unclear to what extent traditional respiratory physiotherapy techniques (e.g. secretion clearance, lung stretch, ventilator weaning and limb care treatments) are used within the respiratory intensive care units where these investigations were conducted. While in most of the studies, exercise training was only provided to the intervention group, both intervention and control groups received standard medical support and nursing care appropriate to their underlying disease or diagnosis. Whether respiratory physiotherapy treatment was incorporated into standard care within these units remains unknown.
Training methods

In one of the earliest investigations of the potential for critically ill patients to exercise, Nava30 reported a complex stepwise pulmonary rehabilitation intervention that increased with subject tolerance in a large group of ventilated respiratory failure patients (N547). The intervention gradually incorporated bed exercise, postural change, sitting out of bed, passive and active movements, lifting weights, pushing against resistance, continuous treadmill walking at 70% of the subjects pre-exercise incremental test,

stationary cycling for 20 minutes (15 watts) and climbing stairs. The intervention group participated in two daily exercise sessions lasting 3045 min. The length of the conditioning programme was different for each subject since individuals continued to exercise until their discharge from the respiratory intensive care unit, although mean length of stay in the intervention group was 38 days. Similarly, Martin et al.6 prescribed a progressive increase in activity determined by subject tolerance in 49 consecutive bed bound ventilator dependant respiratory failure patients. Exercise commenced with sitting at the bed edge, and progressed to training with resistance bands, weights, upper and lower limb cycling, standing, walking and stair climbing. As subjects improved, the conditioning program was lengthened. If subjects could tolerate exercise for 45 min they progressed to twice daily sessions. Conditioning was performed ve days per week. The intensity of the exercise programme was not specied and the number of weeks of the programme remains unknown since subjects continued to exercise until their discharge from the ventilator rehabilitation unit. Length of stay was not reported. Subjects acted as their own controls in this investigation since measurements at admission and discharge were compared. In an Italian respiratory intensive care unit, Zanotti and co-workers7 prescribed exercise twice daily, ve days per week over a four-week period (28 days). Each exercise session built towards 30 min and was comprised of either non-weight bearing active limb mobilisation (actual exercises were not specied) in the control group, or active limb mobilisation and electrically stimulated contractions of quadriceps and glutei in the intervention group. It is unclear whether electrically stimulated contractions were superimposed over the active movements or were completed independently. Chiang and colleagues5 prescribed a training programme consisting of 2 6 10 repetitions of active limb exercise for the wrist, elbow, shoulder, ankle, knee and hip. The upper limb exercises progressed to light resistance (0600 g) while the lower limb exercise progressed to straight leg raising. In addition, bedside functional training (rolling in bed, transfers, sit to stand practice and walking) and facilitated diaphragmatic breathing exercises were performed. The intensity of exercise was level 1011 for the rst week and 1213 thereafter on the 20-point Borg rating of perceived exertion scale (RPE). In the intervention group exercises were completed ve

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Table 3 Summary of exercise training interventions in ventilated respiratory failure patients Score/Rating PEDro (4/10) (Rehab, N 5 60) Standard therapy & level I- IV rehab Participants Interventions Results

Authors

Study

Nava (1998)

Prospective controlled randomised (1 in 3) clinical trial Level 1b (NICE)

NB: not considered ethical to have a (1 in 1) Control 5 14 ventilated (9 invasively, 5 NIV) Mean age (66 8yrs) Diagnosed COPD (ATS definition)

80, clinically stable, bed-ridden, acute respiratory failure, mixed ventilation Rehab 5 47 ventilated (29 invasively, 18 NIV)

Impairment: FEV1 FVC PaCO2 ** pH PaO2/FiO2 MIP ** Walk VAS** HRREST ** HR6MWD** Function: 6MWD** Other: LOS RICU

Zanotti, Felicetti, Maini and Fracchia (2003)

Prospective Randomised

PEDro (4/10)

24, clinically stable, bed ridden for 30 days, invasively ventilated

Level 1b (NICE) Diagnosed COPD (GICLDR def)

Mean age (65.3 8 yrs)

Vs (Control, N 5 20) Standard therapy & Level III Rehab Level I: 2 daily sessions of 3045 min, Posture, Passive and Active Bed ex. Level II: walking retraining. Level III: RMT 2 6 10 min daily against 50% MIP. 20 min cycling am, 5 6 25 stairs pm. Level IV: 2 6 30 min continuous treadmill walking at 70% load. Group 1 (N 5 12): Active Upper and Lower Limb Ex 5 5 days a week 6 4 weeks. Max time as tolerated building to 30 min 6 2 daily (Actual exercises not specified) Group 2 (N 5 12): Active Upper and Lower Limb Ex z Superimposed electrical stimulation of quadriceps femoris & vasti glutei, 5 days a week 6 4 weeks, max time as tolerated building to 30 min 6 2 daily.

Impairment: Mm Strength** SaO2 HR REST RR REST ** Function: Days needed to t/f bed to chair**

Chiang, Wang, Wu, Wu and Wu (2006) Level IIa (NICE)

Prospective controlled

PEDro (4/10)

Thomas

39 clinically stable, alert mechanically ventilated . 14 days. Mean age (72 10yrs) Mixed diagnoses Alternate allocation

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Intervention group (N 5 20) had treatment by a Physical Therapist 5 6 week for 6 weeks 2 6 10 reps upper limb ROM progressing to resistance 2 6 10 reps lower limb ROM Functional training : rolling in bed, transfers, sit to stand, and ambulation. 3 6 10 min daily facilitated diaphragmatic breathing exercises in supine, semi-fowlers and sitting . Control (N 5 19) standard nutritional support, positioning, assistance with ADL and verbal encouragement to physically mobilise.

Impairment: PIMax ** PEMax** Vent Free Time** Maximal Isometric Muscle Strength: Shoulder Flexor** Elbow flexor** Knee extensor** Function: Bartell Index** FIM** 2MWT (m)**

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Table 3 Continued Score/Rating PEDro (N/A) Participants Interventions Standard therapy within the Ventilator Rehabilitation Unit. 3060 min session 6 5 days wk Gradual increase in physical activity from maintenance of body posture to resistance training, upper and lower limb cycle ergometry, standing, walking and stair climbing Inspiratory muscle training 2 6 15 min daily Results

Authors

Study

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Martin, Hincapie, Nimchuk, Gaughan and Criner (2005) Level IIb (NICE)

Retrospective analysis of patient records

NO

49 consecutive clinically stable, bed bound, mechanically ventilated . 14 days. Mean age (58.5 7yrs) Mixed diagnoses

Impairment: Mm strength: Upper Limb* Lower Limb* RR* TV* RR/TV* NIF* Function: FIM - Supine to sit* FIM - Sit to stand* FIM - Ambulation FIM - Stairs

** denotes significant between group differences, * denotes significant admission to discharge group differences. FEV1 5 Forced expiratory volume in the first second. FVC 5 Forced vital capacity. PaCO2 5 Partial pressure of carbon dioxide in arterial blood. pH 5 a measure of the activity of dissolved hydrogen ions in arterial blood. PaO2/FiO2 5 the ratio between the partial pressure of oxygen in arterial blood and the fraction of inspired oxygen. MIP 5 maximal Inspiratory pressure measured at the mouth. VAS 5 visual analogue scale. HR 5 heart rate. 6MWD 5 the distance walked (m) during six minutes. LOS 5 length of stay, RICU 5 respiratory intensive care unit, SaO2 5 the percentage saturation of available heamoglobin with oxygen in arterial blood. RR 5 respiratory rate. PImax 5 maximal inspiratory pressure at the mouth. PEmax 5 maximal expiratory pressure at the mouth. FIM 5 the functional independence measure. 2MWT 5 the distance walked (m) in two minutes. TV 5 Tidal Volume.

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times per week over a six week period. Control subjects received encouragement to exercise but mobilisation was not routinely performed. Both groups received standard care appropriate to their underlying disease but only the intervention group received physiotherapy.
Effects on peripheral muscle strength

The training methods described above elicited increases in peripheral muscle strength (level Ib, IIa and IIb) in respiratory failure patients. For example, 28 days of electrically stimulated exercise intervention elicited a 130% improvement in muscle strength measured with a 5-point ordinal scale.7 The control group improved 68% over baseline values in response to 28 days of active limb mobilisation alone. Electrically stimulated muscle contractions appear to elicit greater increases in peripheral muscle strength than active exercise alone. Similarly, Martin and colleagues6 reported an 89% increase from admission upper limb muscle strength (combined mean scores for shoulder, elbow and wrist exion and extension) and an 80% improvement from admission lower limb muscle strength (combined mean scores for hip, knee and plantar exion and extension) with their training programme. Testing peripheral muscle strength with a hand held dynamometer, Chiang and co-workers5 reported signicant increases in isometric strength of the shoulder exors (40%), elbow exors (69%) and knee extensors (78%) following a six-week physical training programme in their ventilated subjects. Of particular interest in this study, the ventilator dependent group who did not receive physical training demonstrated a 50% reduction in shoulder exor strength, 68% reduction in elbow exor strength and 56% reduction in knee extensor strength over the six-week study period. It appears that decreases in muscle strength occur in critically ill patients who do not receive muscle strengthening exercises.
Effects on functional ability

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Zanotti7 incorporated a number of days to transfer bed to chair functional measure, although it is unclear whether this was a measure of independence in the task or the rst time the activity was attempted. The intervention group receiving electrically stimulated muscle contractions transferred earlier (10.75 days 2.41 days) than the group receiving active limb mobilisation alone (14.33 2.53 days). The Supine to Sit and Sit to Stand components of the Functional Independence Measure (FIM) have also been utilised to assess functional outcome.6 Both components demonstrated an improvement (1.0 to 3.0) although separating individual mobility dimensions from the FIM measurement tool is not recommended practice. Chiang et al.5 utilised the FIM in entirety and reported signicant change in their intervention group (44%) and a decrease (21%) in the control group. The improvements were in activities of daily living (116%) and mobility dimensions (80%) of the FIM. These authors5 also reported a 600% improvement in Bartel Index (BI) scores in the intervention group over their six-week training period.

Conclusions
Evidence of the effectiveness of physical training within the intensive care environment remains limited to long term ventilator dependent respiratory failure patients who may not be representative of a general critically ill population. However, the hierarchy of evidence and grading recommendations relate only to the strength of the literature and not necessarily to its clinical importance. The data reported by Chiang and colleagues5 provides convincing evidence that decreases in muscle strength occur in critically ill patients who do not receive muscle strengthening exercises. In addition, a recent American publication24 has revealed that critical care survivors who received protocol driven physiotherapy intervention within 48hrs of the onset of mechanical ventilation had both decreased ICU (5.5 vs 6.9 days) and hospital stay (11.2 vs 14.5 days) compared with patients who received physiotherapy by referral only. Evaluating the outcome of rehabilitation models employed in the critical care environment remains an urgent necessity for physiotherapists, since these measures are essential to allow the physiotherapist to document the effect of treatment and facilitate audit and research.8 Only 21% of senior physiotherapists surveyed in the United Kingdom8 and 34% surveyed in Australia31 used an outcome measure in their clinical intensive care practice. Critical care

Very few studies have included functional measurements in their outcome assessment. Martin et al.6 report that walking distance increased by 52 ft as a result of their programme and 81% of their bedridden subjects were ambulant at the time of discharge. Nava30 measured exercise tolerance with the six minute walk test and elicited a dramatic improvement (120% increase from baseline) in their intervention group compared with the standard therapy group (52% increase from baseline), although actual mean walk distances are not reported.

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as a whole has lagged behind the evaluation of outcomes compared with less acute settings such as cardiac, pulmonary and neurological rehabilitation. Scales used to measure the functional ability of neurological and elderly populations such as the Functional Independence Measure (FIM), the Bartel Index of Activities of Daily Living (BI) and the six minute walk test may be appropriate for use in the critically ill patient. However, these measurements require validation in a critically ill population and investigation regarding what constitutes clinically signicant change. For example, it has been reported that a 20 point increase in the BI would represent a clinically important change.32 Similarly a 10 point increase in the FIM represents a clinically signicant effect for community stroke survivors.33 Following these criteria, Chiang and colleagues5 reported that 64.7% of their ventilator dependent subjects achieved a clinically signicant change (20 points) in the BI, compared to 100% achieving signicant elevation (10 points) in the FIM score after six weeks of physical training. These authors suggest that the FIM was more sensitive and correlated more strongly with improvements in muscle strength than the BI in their ventilator dependent group. The functional content of the FIM items are at the lower end of the functional activity scale and this instrument may be more relevant for critical care inpatients as these patients have a functional status at the lowest end of the continuum.5 Any examination of functional outcome measures in the critical care environment should include analysis of the validity, reliability, sensitivity (clinically important change) and responsiveness of the tool. It may be necessary for the profession to develop new activity scales for patients at the lowest end of the continuum who fail to score on existing instruments. The relationship between muscle strength, functional scales and other measures of outcome including number of days to wean and length of stay should also be explored. It is clear that research endeavour and funding should be allocated to strengthen and advance physiotherapeutic practice in this high technology, costly health care setting. The physiotherapy profession is poised to consider the distinct and under-appreciated rehabilitative challenge of the critical care patient. Indeed, Hesitation on the part of the intensive care unit physiotherapist is unfortunate because these patients experience greater loss of function than any other patient in any other level of care.21

Acknowledgements
This review was supported in part by a grant from the Research and Development Department Barts and The London NHS Trust. Whitechapel, London, United Kingdom.

References
1 Rivers E, Nguyen B, Havstad S. Early goal directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345(19):136877. Jones, C and Griffiths, RD. Identifying post intensive care patients who may need physical rehabilitation. Clin Intens Care 2000; 11(1):358. Jones, C., Skirrow, P., Griffiths, R., Humphris, G., Ingleby, S., Eddleston, J., Waldermann, C., and Gager, M. Rehabilitation after critical illness: A randomised controlled trial. Crit Care Med 2003; 31(10):245661. Jones, C and McDermott, K (2004). Rehabilitation after critical illness. Br J Intens Care 2004; Winter:1235. 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 (9):127181. Martin, UJ, Hincapie L, Nimchuk M, Gaughan J and Criner, GJ. Impact of whole body rehabilitation in patients receiving chronic mechanical ventilation. Crit Care Med 2005; 33(10):225965. Zanotti, E, Felicetti G, Maini M and Fracchia, C. Peripheral Muscle Strength Training in bed-bound patients with COPD receiving mechanical ventilation. Chest 2003; 124:29296. Lewis, M (2003) Intensive care unit rehabilitation within the United Kingdom. Physiotherapy 2003; 89 (9):5318. Munin MC, Rudy TE, Glynn NW. Early inpatient rehabilitation after elective hip and knee arthroplasty. JAMA 1998; 279 (11):847 52. Mundy LM, Leet TL, Darst K (2003). Early mobilisation of patients hospitalised with community acquired pneumonia. Chest 124(3):8839. Stiller K. Physiotherapy in intensive care, towards an evidencebased practice. Chest 2000; 118:180113. Norrenberg M and Vincent J.L. A profile of European intensive care unit physiotherapists. Intens Care Med 2000; 26:98894. Nava S and Ambrosino N. Rehabilitation in the ICU: the European Phoenix. Intens Care Med 2000; 26:8414. Morris PE. Moving our critically ill patients: mobility barriers and benefits. Crit Care Clin 2007; 23:120. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther 2003; 83:71321. NICE Information for National Collaborating Centres and Guideline Development Groups. The Guideline development process series No 3, 2001; London: National Institute for Clinical Excellence King J and Crowe J. Mobilisation practices of intensive care unit patients. Physiother Canada 1998; 50:20611 Chang A, Boots RJ Hodges PW, Thomas PJ, Paratz J. Standing with the assistance of a tilt table improves minute ventilation in chronic critically ill patients. Arch Phys Med Rehab 2004; 85:1972 6. Stiller K, Phillips A and Lambert P. The safety of mobilisation and its effect on haemodynamic and respiratory status of intensive care patients. Physiother Theory Pract 2004; 20:17585. Olivier FL. Suggested guidelines for the use of exercise with adults in acute care settings Physiother Canada 1998; Spring:127 37. Sciaky AJ. Mobilising the Intensive Care Unit patient: Pathophysiology and Treatment. Phys Ther Pract 1994; 3(2):6980. Stiller K and Phillips A. Safety aspects of mobilising acutely ill inpatients. Physiother Theory Pract 2003; 19:23957. Bailey PR, Thomsen GEM, Spuhler VJR, Blair R, Jeweks J, Bezdjian L, Veale K, Rodriquez L, Hopkins R. Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007; 35(1):13945

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Exercise intervention in the critical care unit

24 Morris PE, Goad A., Thompson C, Taylor K, Harry B, Passmore L., et al. Early ICU Mobility in the treatment of acute respiratory failure. Crit Care Med 2008; 36(8):223843. 25 Stiller K. Safety issues that should be considered when mobilising critically ill patients. Crit Care Clin 2007; 23:3553. 26 Wasserman K and Whipp BJ. Exercise physiology in health and disease Amer Rev Respir Dis 1975; 112:21949. 27 Dean E (1994). Oxygen transport: a physiologically-based conceptual framework for the practice of cardiopulmonary physiotherapy. Physiotherapy 1994; 80:34755 28 Zafiropoulos B, Allison JA, and McCarren, B. Physiological responses to the early mobilisation of the intubated, ventilated abdominal surgery patient. Aust J Physiother 2004; 50:95100.

29 Clini E and Ambrosino N. Early physiotherapy in the respiratory intensive care unit. Respir Med 2005; 99:1096104. 30 Nava S. Rehabilitation of patients admitted to a respiratory intensive care unit. Arch Phys Med Rehabil 1998; 79 (7):849 54. 31 Skinner EH, Berney S, Warrillow S, and Denehy L. Rehabilitation and exercise prescription in Australian intensive care units. Physiotherapy 2008; 94:2209. 32 Wade DT and Collin C. The Barthel ADL Index: a standardised measure of physical disability? Int Disability Stud 1988;10:647. 33 Granger CV, Cotter AC, Hamilton BB, Fielder RC. Functional assessment scales: a study of persons after stroke. Arch Phys Med Rehabil 1993; 74:1338.

AMANDA J. THOMAS Physiotherapy Department, The Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK Tel: z44 0207 377 7000 Bleep 1205; E-mail: Amanda.Thomas@bartsandthelondon.nhs.uk

Published by Maney Publishing (c) W. S. Maney & Son Limited

Physical Therapy Reviews

2009

VOL

14

NO

59