Can Early Rehabilitation on the General Ward After an Intensive Care Unit Stay Reduce Hospital Length of Stay in Survivors of Critical Illness?

Gruther, Wolfgang; Pieber, Karin; Steiner, Irene; Hein, Cornelia; Hiesmayr, Jörg Michael; Paternostro-Sluga, Tatjana

doi:10.1097/phm.0000000000000718

Cited by 52 publications

(50 citation statements)

References 45 publications

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“…Data have suggested that ICU survivors may derive benefit from systematic rehabilitation while receiving treatment during stays in the general hospital ward. 33,36 However, these findings were contradicted by other randomized trials. 32,37 In the present study, because the ethical committee allowed proxy consent in accordance with French law for lowrisk studies, the very early application of interventions was made possible, resulting in a median time between ICU admission and first intervention of approximately 30 hours in both groups.…”

Section: Discussionmentioning

confidence: 95%

Effect of In-Bed Leg Cycling and Electrical Stimulation of the Quadriceps on Global Muscle Strength in Critically Ill Adults

Fossat

Baudin

Courtes

et al. 2018

JAMA

157

146

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IMPORTANCE Early in-bed cycling and electrical muscle stimulation may improve the benefits of rehabilitation in patients in the intensive care unit (ICU). OBJECTIVE To investigate whether early in-bed leg cycling plus electrical stimulation of the quadriceps muscles added to standardized early rehabilitation would result in greater muscle strength at discharge from the ICU. DESIGN, SETTING, AND PARTICIPANTS Single-center, randomized clinical trial enrolling critically ill adult patients at 1 ICU within an 1100-bed hospital in France. Enrollment lasted from July 2014 to June 2016 and there was a 6-month follow-up, which ended on November 24, 2016. INTERVENTIONS Patients were randomized to early in-bed leg cycling plus electrical stimulation of the quadriceps muscles added to standardized early rehabilitation (n = 159) or standardized early rehabilitation alone (usual care) (n = 155). MAIN OUTCOMES AND MEASURES The primary outcome was muscle strength at discharge from the ICU assessed by physiotherapists blinded to treatment group using the Medical Research Council grading system (score range, 0-60 points; a higher score reflects better muscle strength; minimal clinically important difference of 4 points). Secondary outcomes at ICU discharge included the number of ventilator-free days and ICU Mobility Scale score (range, 0-10; a higher score reflects better walking capability). Functional autonomy and health-related quality of life were assessed at 6 months. RESULTS Among 314 randomized patients, 312 (mean age, 66 years; women, 36%; receiving mechanical ventilation at study inclusion, 78%) completed the study and were included in the analysis. The median global Medical Research Council score at ICU discharge was 48 (interquartile range [IQR], 29 to 58) in the intervention group and 51 (IQR, 37 to 58) in the usual care group (median difference, −3.0 [95% CI, −7.0 to 2.8]; P = .28). The ICU Mobility Scale score at ICU discharge was 6 (IQR, 3 to 9) in both groups (median difference, 0 [95% CI, −1 to 2]; P = .52). The median number of ventilator-free days at day 28 was 21 (IQR, 6 to 25) in the intervention group and 22 (IQR, 10 to 25) in the usual care group (median difference, 1 [95% CI, −2 to 3]; P = .24). Clinically significant events occurred during mobilization sessions in 7 patients (4.4%) in the intervention group and in 9 patients (5.8%) in the usual care group. There were no significant between-group differences in the outcomes assessed at 6 months. CONCLUSIONS AND RELEVANCE In this single-center randomized clinical trial involving patients admitted to the ICU, adding early in-bed leg cycling exercises and electrical stimulation of the quadriceps muscles to a standardized early rehabilitation program did not improve global muscle strength at discharge from the ICU.

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Section: Discussionmentioning

confidence: 95%

Effect of In-Bed Leg Cycling and Electrical Stimulation of the Quadriceps on Global Muscle Strength in Critically Ill Adults

Fossat

Baudin

Courtes

et al. 2018

JAMA

157

146

View full text Add to dashboard Cite

show abstract

“…Therapy dosage was also demonstrated to be a problem in a similar, but adequately powered, early rehabilitation trial in multi-trauma patients (31). These results, together with those of similar trials (28)(29)(30), emphasize that therapy dose is an important consideration that needs to be further characterized in the early/acute rehabilitation setting. They also highlight the importance of monitoring intervention fidelity and evaluating the real-world dose of therapy delivered in rehabilitation trials, in order to draw valid and meaningful conclusions about the dose of therapy required to improve outcomes (32).…”

Section: Discussionmentioning

confidence: 75%

“…Since the time of conception of this pilot study, there have been 3 other trials of early rehabilitation programmes in this patient population, each exploring a different intervention, but focused mainly on physiotherapy. Gruther and colleagues (28) showed, in a randomized controlled trial (n = 53), that an early rehabilitation programme using additional physiotherapy on the acute ward for intensive care survivors led to earlier discharge from hospital. This study found a median 7-day reduction in hospital LOS, although long-term follow-up outcomes were not assessed.…”

Section: Discussionmentioning

confidence: 99%

“…They also used a number of criteria to select patients who were more likely to benefit from an early rehabilitation programme. Gruther et al's trial (28) was able to deliver a mean of 114 ± 58 min/day of therapy in the intervention group compared with 21 ± 46 min/day of therapy in the standard-care group, representing a 543% increase in therapy dose. Our study achieved less than a 2-fold increase in combined physiotherapy and occupational therapy compared with standard care, which probably contributed to our divergent results.…”

Section: Discussionmentioning

confidence: 99%

“…Patient selection is another important consideration for future rehabilitation trials that was not explicitly addressed in the present study. Gruther et al (28) utilized a rehabilitation physician (physiatrist) to clinically assess patients in order to identify those most likely to benefit from their intervention and subsequently report the only positive findings published to date. Thus, developing a screening process to enable identification of those patients most likely to benefit from a targeted early rehabilitation programme is worthy of further investigation.…”

Section: Discussionmentioning

confidence: 99%

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Can in-reach multidisciplinary rehabilitation in the acute ward improve outcomes for critical care survivors? A pilot randomized controlled trial

Wu¹,

Vratsistas-Curto²,

Shiner³

et al. 2019

J Rehabil Med

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This pilot study aimed to assess whether early, structured rehabilitation can be provided to critical care survivors and aid physical and psychological recovery. The study recruited 66 participants who were critically ill and were in intensive care for at least 5 days. The study compared patients receiving early rehabilitation in addition to usual therapy, vs usual therapy on the acute ward. Both participant groups were assessed at hospital discharge and at 6 and 12 months. The outcomes assessed included: length of hospital stay; mobility ability to carry out activities of daily living; psychological symptoms; and quality of life. The results showed that early rehabilitation was feasible, could be provided to critical care survivors, and suggested that these patients may have a shorter length of stay in hospital. While both groups improved in their other outcomes, there were no major differences between the groups. Objectives: To assess the feasibility of in-reach rehabilitation for critical care survivors following discharge from the intensive care unit. To determine whether additional in-reach rehabilitation reduces hospital length-of-stay and improves outcomes in critical care survivors, compared with usual therapy. Participants: A total of 66 consecutively-admitted critical care survivors with an intensive care unit stay ≥ 5 days were enrolled in the study. Of these, 62 were included in the analyses. Methods: Pilot randomized control trial with blinded assessment at 6 and 12 months. The intervention group (n = 29) received in-reach rehabilitation in addition to usual ward therapy. The usual-care group (n = 33) received usual ward therapy. The primary outcome assessed was length-of-stay. Secondary outcomes included mobility, functional independence, psychological status and quality-of-life. Results: The intervention group received more physiotherapy and occupational therapy sessions per week than the usual-care group (median = 8.2 vs 4.9, p < 0.001). Total length-of-stay was variable; while median values differed between the intervention and usual care groups (median 31 vs 41 days), this was not significant and the pilot study was not adequately powered (p = 0.57). No significant differences were observed in the secondary outcomes at hospital discharge, 6-or 12-month follow-ups. Conclusion: Provision of intensive early rehabilitation to intensive care unit survivors on the acute ward is feasible. A further trial is needed to draw conclusions on how this intervention affects lengthof-stay and functional outcomes.

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Effect of Exercise Intervention on Functional Decline in Very Elderly Patients During Acute Hospitalization

et al. 2019

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IMPORTANCE Functional decline is prevalent among acutely hospitalized older patients. Exercise and early rehabilitation protocols applied during acute hospitalization can prevent functional and cognitive decline in older patients. OBJECTIVE To assess the effects of an innovative multicomponent exercise intervention on the functional status of this patient population. DESIGN, SETTING, AND PARTICIPANTS A single-center, single-blind randomized clinical trial was conducted from February 1, 2015, to August 30, 2017, in an acute care unit in a tertiary public hospital in Navarra, Spain. A total of 370 very elderly patients undergoing acute-care hospitalization were randomly assigned to an exercise or control (usual-care) intervention. Intention-to-treat analysis was conducted. INTERVENTIONS The control group received usual-care hospital care, which included physical rehabilitation when needed. The in-hospital intervention included individualized moderate-intensity resistance, balance, and walking exercises (2 daily sessions). MAIN OUTCOMES AND MEASURES The primary end point was change in functional capacity from baseline to hospital discharge, assessed with the Barthel Index of independence and the Short Physical Performance Battery (SPPB). Secondary end points were changes in cognitive and mood status, quality of life, handgrip strength, incident delirium, length of stay, falls, transfer after discharge, and readmission rate and mortality at 3 months after discharge. RESULTS Of the 370 patients included in the analyses, 209 were women (56.5%); mean (SD) age was 87.3 (4.9) years. The median length of hospital stay was 8 days in both groups (interquartile range, 4 and 4 days, respectively). Median duration of the intervention was 5 days (interquartile range, 0); there was a mean (SD) of 5 (1) morning and 4 (1) evening sessions per patient. No adverse effects were observed with the intervention. The exercise intervention program provided significant benefits over usual care. At discharge, the exercise group showed a mean increase of 2.2 points (95% CI, 1.7-2.6 points) on the SPPB scale and 6.9 points (95% CI, 4.4-9.5 points) on the Barthel Index over the usual-care group. Hospitalization led to an impairment in functional capacity (mean change from baseline to discharge in the Barthel Index of −5.0 points (95% CI, −6.8 to −3.2 points) in the usual-care group, whereas the exercise intervention reversed this trend (1.9 points; 95% CI, 0.2-3.7 points). The intervention also improved the SPPB score (2.4 points; 95% CI, 2.1-2.7 points) vs 0.2 points; 95% CI, −0.1 to 0.5 points in controls). Significant intervention benefits were also found at the cognitive level of 1.8 points (95% CI, 1.3-2.3 points) over the usual-care group. CONCLUSIONS AND RELEVANCE The exercise intervention proved to be safe and effective to reverse the functional decline associated with acute hospitalization in very elderly patients. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02300896

show abstract

Can Early Rehabilitation on the General Ward After an Intensive Care Unit Stay Reduce Hospital Length of Stay in Survivors of Critical Illness?

Cited by 52 publications

References 45 publications

Effect of In-Bed Leg Cycling and Electrical Stimulation of the Quadriceps on Global Muscle Strength in Critically Ill Adults

Effect of In-Bed Leg Cycling and Electrical Stimulation of the Quadriceps on Global Muscle Strength in Critically Ill Adults

Can in-reach multidisciplinary rehabilitation in the acute ward improve outcomes for critical care survivors? A pilot randomized controlled trial

Effect of Exercise Intervention on Functional Decline in Very Elderly Patients During Acute Hospitalization

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