RESPIRATORY REHABILITATION: Broader scope, extended focus

1895

1960 1977

‘The physiotherapist will come do exercises on your chest’

1990 1990

LUNGS AND

AIRWAYS

CHEST WALL

AND RESPIRATORY MUSCLES

HEART AND CIRCULATION

LIMB MUSCLES

ANXIETY AND MOTIVATION

Casaburi & ZuWallack NEJM 2009

www.fysionet.nl

www.cebp.nl

www.bvp-sbp.org

Dutch

English

French

Portugese

Retained secretions Lung collaps Weaning

Deconditioning

Inactivity

Emotional functioning

Deconditioning

Inactivity

Herridge et al. N.Engl.J.Med. 2003/2011

%pr

edicte

d

RECOVERY AFTER ARDS

months

‘Our results suggest that the inability to exercise is primarily due

to extrapulmonary disease; our impression is that impaired muscle function had an important effect on

the long-term outcomes in these patients’

Herridge et al. N.Engl.J.Med. 348:683-693, 2003

Helliwell et al. Neuropathology and Appl Neurobiol. 24, 507-517, 1998.

Type I

Type II

~ 3% per day

~ 4% per day

Limb muscle weakness in critically ill patients

Schefold et al. J Cach Sarcop Muscle 2010; 1:147

Gruther et al. J Rehabil Med 2008; 40: 185–189

Thigh muscle layer thickness in critically ill ventilated patients

Thigh t

hickne

ss (cm

)

ICU stay (days)

Iwashyna TJ AJRCCM 2012: 186:302

“The physician must always consider

complete bed rest as a highly

unphysiologic and definitely hazardous form of therapy, to be ordered only for

specific indications and discontinued as early as possible”.

The indications for which bed rest should be

prescribed, and for how long, are yet to be defined.

Dock W. The evil sequelae of complete bed rest. JAMA 1944; 125:1083 – 85 .

Rest

Stimulus

Current AND Pre-existent comorbid conditions

Modality Intensity Duration

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

2 : FAILS = at least 1 risk factor present / 3 : if basic assessment failed, decrease to level 0 4 : safety: each activity should be deferred if severe adverse events (cv., resp. and subject. intolerance) occur during the intervention

Neurological or surgical or trauma condition does not allow transfer to chair

NO-LOW COOPERATION

S5Q1 < 3

MODERATE COOPERATION

S5Q1 ≥ 3

CLOSE TO FULL COOPERATION

S5Q1 ≥ 4/5

FULL COOPERATION

S5Q1 = 5

PHYSIOTHERAPY4

Passive range of motion

Passive bed cycling

NMES

BODY POSITIONING4

2hr turning

Fowler’s position

Splinting

PHYSIOTHERAPY4

Passive/Active range of motion

Resistance training arms and legs

Passive/Active leg and/or cycling in bed or chair

NMES

BODY POSITIONING4

2hr turning

Splinting

Upright sitting position in bed

Passive transfer bed to chair

PASSES BASIC ASSESSMENT3 +

PASSES BASIC ASSESSMENT3 +

PHYSIOTHERAPY4

Passive/Active range of motion

Resistance training arms and legs

Active leg and/or arm cycling in bed or chair

NMES

ADL

BODY POSITIONING4

2hr turning

Passive transfer bed to chair

Sitting out of bed

Standing with assist (2 ≥ pers)

PASSES BASIC ASSESSMENT3 +

PHYSIOTHERAPY4

Passive/Active range of motion

Resistance training arms and legs

Active leg and/or arm cycling in chair or bed

Walking (with assistance/frame)

NMES

ADL

PASSES BASIC ASSESSMENT3 +

LEVEL 0 LEVEL 5

FULL COOPERATION

S5Q1 = 5

PHYSIOTHERAPY4

Passive/Active range of motion

Resistance training arms and legs

Active leg and arm cycling in chair

Walking (with assistance)

NMES

ADL

BODY POSITIONING4

Active transfer bed to chair

Sitting out of bed

Standing

PASSES BASIC ASSESSMENT3 +

LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4

Obesity or neurological or surgical or trauma condition does not allow active transfer to chair (even if MRCsum ≥ 36)

MRCsum ≥ 36 +

BBS² Sit to stand = 0 +

BBS² Standing = 0 +

BBS² Sitting ≥ 1

MRCsum ≥ 48 +

BBS² Sit to stand ≥ 0 +

BBS² Standing ≥ 0 +

BBS² Sitting ≥ 2

MRCsum ≥ 48 +

BBS² Sit to stand ≥ 1 +

BBS² Standing ≥ 2 +

BBS² Sitting ≥ 3

NO COOPERATION

S5Q1 = 0

FAILS BASIC ASSESSMENT2

PHYSIOTHERAPY:

No treatment

BODY POSITIONING4

2hr turning

BASIC ASSESSMENT =

- Cardiorespiratory unstable:

MAP < 60mmHg or

FiO2 > 60% or

PaO2/FiO2 < 200 or

RR > 30 bpm

- Neurologically unstable

- Acute surgery

-Temp > 40°C

BODY POSITIONING4

Active transfer bed to chair

Sitting out of bed

Standing with assist (≥1 pers)

UZLEUVEN ‘START TO MOVE' ASAP

Exercise training

Mobilisation – Body positioning

Active muscle (resistance) training Transcutaneous electrical muscle stimulation

Passive stretching and range

of motion exercise

MODALTIES FOR PHYSICAL TRAINING

UNSTABLE-BED RIDDEN-UNCOOPERATIVE

STABLE-COOPERATIVE

Daily Mobility Team Interventions (n=165)

‘Usual’ care: Physical Therapy on physician order (n=166)

Critically ill patient < 48 hours MV

Morris et al. Crit. Care Med. 2008: 36: 2238

Morris et al. Crit. Care Med. 2008: 36: 2238

0

5

10

15

20

First Out Bed Ventilator ICU LOS Hospital LOS

Usual Care Mobility Team

* #

*

Morris et al. Crit. Care Med. 2008;36: 2238

Days

(median)

Daily Physical and/or Occupational Therapy

‘Usual’ care: Physical and/or Occupational Therapy on physician order

Critically ill patient • < 72 hours MV and forecast of at least another 24hour on MV • Barthel Index > 70 (max 100) in 2 weeks before admission

Schweikert et al. Lancet 2009; 373:1874-1882

Contraindication to Rehabilitation Intervention

(43% of ICU days)

Sedation Shock Renal support

Out of ICU Acute Respiratory Distress Extubation

Cognitive alteration

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

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

2 : FAILS = at least 1 risk factor present / 3 : if basic assessment failed, decrease to level 0 4 : safety: each activity should be deferred if severe adverse events (cv., resp. and subject. intolerance) occur during the intervention

Neurological or surgical or trauma condition does not allow transfer to chair

NO-LOW COOPERATION

S5Q1 < 3

MODERATE COOPERATION

S5Q1 ≥ 3

CLOSE TO FULL COOPERATION

S5Q1 ≥ 4/5

FULL COOPERATION

S5Q1 = 5

PHYSIOTHERAPY4

Passive range of motion

Passive bed cycling

NMES

BODY POSITIONING4

2hr turning

Fowler’s position

Splinting

PHYSIOTHERAPY4

Passive/Active range of motion

Resistance training arms and legs

Passive/Active leg and/or cycling in bed or chair

NMES

BODY POSITIONING4

2hr turning

Splinting

Upright sitting position in bed

Passive transfer bed to chair

PASSES BASIC ASSESSMENT3 +

PASSES BASIC ASSESSMENT3 +

PHYSIOTHERAPY4

Passive/Active range of motion

Resistance training arms and legs

Active leg and/or arm cycling in bed or chair

NMES

ADL

BODY POSITIONING4

2hr turning

Passive transfer bed to chair

Sitting out of bed

Standing with assist (2 ≥ pers)

PASSES BASIC ASSESSMENT3 +

PHYSIOTHERAPY4

Passive/Active range of motion

Resistance training arms and legs

Active leg and/or arm cycling in chair or bed

Walking (with assistance/frame)

NMES

ADL

PASSES BASIC ASSESSMENT3 +

LEVEL 0 LEVEL 5

FULL COOPERATION

S5Q1 = 5

PHYSIOTHERAPY4

Passive/Active range of motion

Resistance training arms and legs

Active leg and arm cycling in chair

Walking (with assistance)

NMES

ADL

BODY POSITIONING4

Active transfer bed to chair

Sitting out of bed

Standing

PASSES BASIC ASSESSMENT3 +

LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4

Obesity or neurological or surgical or trauma condition does not allow active transfer to chair (even if MRCsum ≥ 36)

MRCsum ≥ 36 +

BBS² Sit to stand = 0 +

BBS² Standing = 0 +

BBS² Sitting ≥ 1

MRCsum ≥ 48 +

BBS² Sit to stand ≥ 0 +

BBS² Standing ≥ 0 +

BBS² Sitting ≥ 2

MRCsum ≥ 48 +

BBS² Sit to stand ≥ 1 +

BBS² Standing ≥ 2 +

BBS² Sitting ≥ 3

NO COOPERATION

S5Q1 = 0

FAILS BASIC ASSESSMENT2

PHYSIOTHERAPY:

No treatment

BODY POSITIONING4

2hr turning

BASIC ASSESSMENT =

- Cardiorespiratory unstable:

MAP < 60mmHg or

FiO2 > 60% or

PaO2/FiO2 < 200 or

RR > 30 bpm

- Neurologically unstable

- Acute surgery

-Temp > 40°C

BODY POSITIONING4

Active transfer bed to chair

Sitting out of bed

Standing with assist (≥1 pers)

UZLEUVEN ‘START TO MOVE' ASAP

Exercise training

Mobilisation – Body positioning

Active muscle (resistance) training

Transcutaneous electrical muscle stimulation

Passive stretching and range of

of motion exercise

MODALTIES FOR PHYSICAL TRAINING

ACUTE-INSTABLE-UNCOOPERATIVE

CHRONIC-STABLE-COOPERATIVE

Effect of passive stretching on the wasting of muscle in the

critically ill

Griffiths et al. Nutrition 1995; 11:428-432

Protocol

1 leg 3 hours passive motion, 3 times per day, mainly ankle motion (25% passive stretch Ant.Tibialis)

1 leg flat position

twice daily passive

motion (5 min) both legs

140%

120%

100%

80%

60%

40%

20%

0%

1

2

3

4

5

% c

hang

e f

iber

are

a

Con1 Con2 CPM1 CPM2

Griffiths et al. Nutrition 1995; 11:428-432

less severe

p< 0.02 (more severe)

Passive stretching 10 h per day in addition to ‘Usual’ care

‘Usual’ care: respiratory physiotherapy mobilisation

7 critically ill patient • 0-3 days ICU and forecast of at least 10 days at the ICU

Study design

Llano-Diez et al. Crit Care 2012; 16:2499-2505

Llano-Diez et al. Crit Care 2012; 16:2499-2505

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

‘Usual’ care: respiratory physiotherapy mobilisation

Critically ill patient • ’5 days ICU and forecast of another 7 days at the ICU

Study design

Burtin et al. Crit Care Med 2009; 37:2499-2505

ICU and Hospital stay

0

5

10

15

20

25

30

35

40

45

ICU stay Hospital stay

Control

Treatment

Days

Burtin et al. Crit Care Med 2009

TR CO

0

100

200

300

400

500

600

p < 0.056M

WD

(m

)

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

43 m

TR CO

10

15

20

25

30 p < 0.05

SF

-36

PF

sco

re (

10-3

0)

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

TR CO TR CO1.0

1.5

2.0

2.5

3.0

ICU discharge hospital discharge

QF

(N

/kg

)

p < 0.01

p < 0.05

Exercise training

Mobilisation – Body positioning

Active muscle (resistance) training

Transcutaneous electrical muscle stimulation

Passive range of motion exercise

MODALTIES FOR PHYSICAL TRAINING

ACUTE-INSTABLE-UNCOOPERATIVE

CHRONIC-STABLE-COOPERATIVE

100% 75- 99% 50- 75% 1- 50% 0% Segers et al. under review

DOES NMES ACHIEVE SUCCESSFULLY MUSCLE CONTRACTIONS IN ICU PATIENTS?

Responders Non-responders P-value

Gender (M/F) 14/8 8/14 .07

Age, yrs (mean +/-

SD )

56 (12) 63 (10) .07

APACHE II 25 (9) 27 (6) 0,523

Glasgow Coma

Scale

7 (3) 9 (3) 0,063

Intensity (mA) 64 (8) 68 (13) 0,297

BMI, kg/m² (mean

+/-SD)

25,4 (4,3) 25,6 (5,4) .916

Edema (n) n= 8 n= 16 0,015

Diagnosed with

sepsis

7 13 .037

Segers et al. under review

Mortality and ARDS

Iwashyna TJ AJRCCM 2012: 186:302

Unroe et al. Ann Intern Med 2010: 153:167

Health outcome at 3 months

Good

Fair

Poor

Ries et al. Ann.Intern Med. 1995; 122: 823

CONCLUSIONS I

CONCLUSIONS II

REACHING OUT BEYOND THE BORDERS:

THE CHALLENGE OF ADJUSTING THE SAILS

PULMONARY REHABILITATION TEAM

Acknowledgements ICU PHYSICAL THERAPY TEAM

CARDIOVASCULAR AND RESPIRATORY RESEARCH GROUP