Physiotherapy ICU Management Algorithm

PHASE 2: Based on feedback from phase 1 the following issues were discussed :

Defining the term “therapist judgment”: The term "based on therapist judgment" currently used in the recommendation implies all standard actions routinely taken by therapists before deciding to initiate an intervention. This includes interdisciplinary discussions with specific team members, as well as multi system and detailed assessments of oxygen transport threats and deficits.

POSTED COMMENTS:

I have significant concerns about how therapist judgement is defined. For example in our work many therapists do not believe that many cricially ill patients can be ambulated. As such judgement based on limited information is often incorrect. That as the patients could be ambulated safely. How will theapists be "trained" to make sure judgements are based on the patients physiologic condidtion and not terapist hbiases?
I think it is more than that. Therapist's judgement also covers their past clinical experience and knowledge of research findings.

Description of measures that could ensure continuation of activity: The adjustment of FiO2 to maintain sufficient oxygenation is a safe and effective measure which will allow continuation of activity (Stiller et al 2004; Bailey et al 2007; Thomsen et al 2008) and is therefore specifically mentioned in the recommendation. Other measures described e.g. laying down following an orthostatic hypotensive episode (Bailey et al 2007) resulted in the discontinuation of activity. Increases in HR and BP noted by Stiller et al (2004) did not result in direct medical intervention.

POSTED COMMENTS:

Reformulation of recommendation 2: An individually designed early activity mobility plan MUST be developed for each critically ill patient admitted to an ICU, in accordance with their assessment and needs and in consultation with the interdisciplinary team. This plan must include objective measures linked to specific formulated goals.

POSTED COMMENTS:

Reformulation of the strength of recommendation 2: An individually designed early activity mobility plan MUST be developed for each critically ill patient admitted to an ICU, in accordance with their assessment and needs and in consultation with the interdisciplinary team. This plan must include objective measures linked to specific formulated goals.

POSTED COMMENTS:

Criteria for the initiation of a specific exercise program:
Patients that have been physiologically to unstable to initiate early activity, for a prolonged period of time (panel members suggest 5 days; literature suggests 14 days) could benefit from a targeted exercise program in addition to ambulation once the underlying cause of physiologic instability has been resolved. MOTIVATION: The deconditioning following prolonged periods of immobility or decreased mobility need to be addressed specifically, once the underlying cause of the initial instability has been resolved. Nava et al 1998 and Chiang et al 2006 compared the effect of a specific targeted exercise program in addition to ambulation with ambulation only. Significant gains in 6MWD, patient perception of dyspnea and muscle strength in the exercise group when compared to the ambulation group were reported. Martin et al 2005 reported improvement in both function and strength following a whole body rehabilitation program in chronically ventilated patients. The inclusion criteria for entry into these studies were Nava (3-5 days after transfer to RICU: which was at least 5 days after intubation; and clinically stable) Martin (patients who were clinically stable and had been ventilated for more than 14 days); Chiang et al (patients ventilated for at least 14 days; mentally alert, and hemodynamically stable).

POSTED COMMENTS:

Why set a specific time period to wait , why not define physiologic stabiltiy and then initiate exercise/activity program based on the patient? The comparison studies are all "chonic vent" pateints. By using actiivty and ambulation, we may not only prevent deconditioning but reduce the numbers of patients who require mechanical ventilation for prolonged periods of time as the patients in the Martin, nava, and Chaing studies.
would suggest to keep 5 days as starting point for more focus in the treatment to (further) prevention of deconditioning in patients with an expected prolonged ICU stay. This might be in addition to ambulation, but can, in patients unstable/unable to ambulate, also be other modalities of 'exercise', without ambulation
I almost agree! It's just that there are some critically ill patients where an early mobility plan is clearly NOT appropriate - eg dying, on death's door etc because of critical illness. In these cases obviously you delay mobility (temporarily or permanently). Still, I guess this may be covered by the latter part of the sentence ie "in accordance with their assessment and needs ..."
Contemporary physical therapists practice based on their assessments vs. ‘days’ or ‘protocols’. I strongly recommend not specifying days or protocols in any recommendation – these take up backward in our professional growth and autonomy. I believe that a recommendation should stand alone. Certainly, recomendations need to be defensible, but need not include the literature within them. The rationale should be separate (perhaps precede each recommendation).

The activities to include: The exercise program should include low resistance and multiple repetitions of resistive muscle training. The muscles that should be targeted include the trunk, upper extremities, and lower extremities. A progressive ambulation program should also be included. MOTIVATION: Nava et al (2002) advocated specificity of training as an important factor to consider when deciding on an exercise program for ICU patients. Trunk muscles are necessary to maintain an upright position; and upper and lower extremities for functional activities including eating; dressing; transfers and ambulation (Chiang et al 2006; Nava et al 1998; Martin et al 2005)The training of these muscles resulted in improved function measured by FIM (Chiang et al 2006; Martin et al 2005); dyspnea rating and 6 MWD (Nava et al 1998).

POSTED COMMENTS:

Muscle training and ambulation should be done concurrently. - which may be what is suggested by saying "A progressive ambulation program should also be included". I would say muscle training and ambulation are BOTH included silmutaneously as part of the excercise program
I almost agree! It's just that there are some critically ill patients where an early mobility plan is clearly NOT appropriate - eg dying, on death's door etc because of critical illness. In these cases obviously you delay mobility (temporarily or permanently). Still, I guess this may be covered by the latter part of the sentence ie "in accordance with their assessment and needs ..."
I disagree with the first sentence of this recommendation. What about all the patients in ICU with critical illness myopathy or polyneuropathy or disuse muscle atrophy that is unable to do low resistance, multiple repetitions of resistive muscle training. The exercise program should therefore be patient specific e.g. active assistive to active and then progress to resisted muscle training. Secondly, i believe it is more benefiscial to do a functional activity (Closed weight bearing activity) such as rolling, bridging, sitting up on the edge of the bed or standing if able when one is at the resisted muscle training phase of a patient instead of doing open kinematic chain activities with the patient. Clinically the patient progress much quicker and psychologically it means a lot more to the patient.
Actually I'm happy with the comments above. But, you may also need to incorporate higher resistance exs if strength (as well as endurance) is a problem.
I have reservations with 'should' in every sentence. I would suggest 'should be considered'

Intensity and frequency of the intervention: This exercise program should be implemented at least once daily progressing to twice a day. The intensity of the training needs to be guided by the patient's tolerance of the exercise. MOTIVATION: Nava et al 2002 advocated threshold and specificity of training as important factors to consider when deciding on a program for ICU patients. The threshold of training refers to the intensity needed to have an affect on the muscle without causing damage to the muscle. Chiang reported a daily exercise program with exercise intensity judged based on the Borg Rating of Perceived Exertion Scales (RPE). The rating of perceived exertion was set at 10 to 11. Martin reported 45 min sessions at least once a day progressing to twice daily sessions once patients were able to tolerate a single session.

POSTED COMMENTS:

Too prescriptive. I agree that should be at least once daily, but progress to as much as is appropriate - this may be twice a day, it may be more
We do not have data to support daily sessions and once or twice a day sessions. From clinical experience I would support aiming at daily sessions, but consider carefully balance between exerise and rest. Other activities, normally not considered as 'exercise' like eating, drinking, clinical examination, personal care, family visits, might already be demanding for the critically ill patient. In our clinical and research experience exercise was involved in the treatment on 4 out of 7 days.
I would strongly discourage specifying specifics as these really need to come from the patient indications and response. Some patients may need 10 visits a day and others one – although funding may not be in place we need to aim high and provide services as frequently as patients need including weekends. Martin’s findings are not necessarily helpful as these arbitrary numbers should not guide the intervention for a given patient

PHASE 2: Based on feedback from phase 1 the following issues were discussed:

Defining unresponsive patients : Patients that do not have the pulmonary; cardiovascular or neurological reserve described by Stiller et al 2004 and Bailey et al 2007 (minimal physiologic stability) for the initiation of early activity should not be excluded from a minimal mobility plan. The effect of medication on patient’s ability to respond to verbal commands as well as the need for sedation should be discussed with the interdisciplinary team members. The goal is to progress to a conscious state of active participation as soon as possible.

POSTED COMMENTS:

Activities included: The core elements of a mobility plan for patients that have not reached the physiological stability to initiate early activity include semi-recumbent positioning with the goal of 45 degree head up; regular position change (current standard is turning every two hours), and daily passive movement of all joints. The patient must be screened daily and active mobility initiated as soon as possible. MOTIVATION: The proposed POSITIONING OF THE PATIENT prevents the development of VAP (Dodek et al 2004) and could stimulate the physiologic beneficial effect of an upright body position (Gosselink et al 2008). The FREQUENT POSITION CHANGE could prevent pulmonary complications (Goldhill et al 2007) and have a physiological “stir-up effect” on the pulmonary and cardio vascular systems (Gosselink et al 2008). Thirty nine percent of patients that remained in ICU for longer than two weeks presented with function impairing joint contractures at discharge from a ICU (Clavet et al 2008). As the formation of contractures is related to immobility; it could be argued that PASSIVE MOBILIZATION is better than no mobilization. (The intensity and frequency is not clear; panel members suggesting 5 repetitions daily) Even though Zanotti et al (2002) reported a significant improvement in muscle strength when combining ELECTRICAL STIMULATION and active limb movement in awake, ventilated, bed bound patients, it is not clear whether this intervention in patients that do not have the pulmonary; cardiovascular or neurological reserve to initiate active movement is safe and is therefore not included. (Goldhill et al 2007 Rotational bed therapy to prevent and treat respiratory complications: a review and Meta analysis. Amer Journal of Crit care 16:50-62; Clavet et al 2008 Joint contracture following prolonged stay in the intensive care unit. CMAJ 178:691-7; Thomsen et al 2008 Respiratory failure patients increase ambulation after transfer to an ICU where early activity is a priority. Crit Care Med 36:1119-1124)

POSTED COMMENTS:

We do not consider sitting with head up or passive range of motion activity - but rather required for joint maintence. Agree the sitting should be done along with PROM but these should not be considered activitiy. Suggest increasing evaluation of patients for activity from once a day to twice a day.
I still would prefer if we said something like: passive movements may be beneficial in preventing / minimising joint contractures. The 'may' is the important word as it sits on the fence, which is all you can really do at the moment with the current level of evidence.
In addition to changing body position, paasive (joint) motion (5 reps) also repetitive movement (passive/active) of lower limbs can be performed for 15 minutes (daily or every other day).
Avoid numbers eg 45 degrees. We need patients to tolerate the highest upright positions as possible and a range of body positions when in bed (extreme body positions frequently that best simulate life and being upright and moving as soon as indicated.