Evidence Based Practice: A Comprehensive Literature Review on Early Mobility

Evidence Based Practice:A Comprehensive Literature Review on Early Mobility Courtney Bixman - Witczak, DPT Kim Dosch, PT University of Michigan October 27, 2012

Why Early Mobility? • Benefits: • Promote the maximal level of functional independence before discharge • Decreased risk of neuromuscular abnormalities and physical impairments • Decreased ventilator and hospital acquired diseases • Decreased length of stay in the ICU and in the hospital Decreased duration of mechanical ventilation • Decreased hospital costs • Improved quality of life upon discharge

A Quick Review: Effects of Bedrest • “Bed rest was not beneficial and may be associated with harm” –Desai (2011) • Chronic critical illness is associated with prolonged immobility and accounts for 5-10 % of all ICU stays • 5 million + patients experiencing an ICU stay each year • Bedrest leads to negative effects on almost every system in the body

Cardiovascular Effects • Heart Rate • Elevated heart rate • Reduced heart rate variability • Increased sympathetic tone • Decreased plasma volume • Decreased stroke volume • Reduction in cardiac output • Orthostatic instability

Pulmonary Effects • Changes in ventilation and perfusion • Atelectasis • Aspiration • Increased risk for ventilator acquired pneumonia (VAP) and hospital acquired pneumonia • Hypoxia

Musculoskeletal Effects • Muscle Atrophy • Begins with in hours of immobility • Strength decreases by 1-1.5% per day • Muscle wasting highest in first 2-3 weeks of ICU stay • After 7 days of mechanical ventilation, 25-33% of patients experience clinically visible weakness • ICU acquired paresis • Joint Contractures • Bone Degradation

Renal Effects • Renal stone formation • Renal impairment and progression of kidney failure Gastrointestinal & Metabolic Effects • Aspiration • GERD • Insulin Resistance

Cognition, Sleep, Pain Effects • ICU Delirium • Memory • Altered sleep-wake cycle • Back pain • Altered cutaneous pain perception

Integumentary System • Immobolized patients are at higher risk for skin breakdown and delayed healing since the skin can not tolerate prolonged pressure • Interruptions in the skin barrier place the patient at a higher risk of health acquired diseases

Functional Limitations • Activity Intolerance • Difficulty with ADLs • Reduced Quality of Life

PT involvement in the ICU • Chronic critical illness associated with prolonged immobility and intensive care unit stay accounts for 5-10% of ICU stays. • Patient’s exposure to PT services while in the ICU varies by setting. • Early mobility PT treatment in the ICU varies throughout the country • Must be a team approach in order to have success mobilizing a mechanically ventilated patient

Feasibility and Safety • Key Points • Pre- planning treatment sessions through daily communication with the ICU team members • Appropriate clinical decision making • Dialysis • Weaning from the ventilator • Determine appropriateness for PT intervention

Perme et al (2009) • Reasons to discontinue treatment • Drop in oxygen saturation below 88% while on supplemental oxygen • Drop in mean arterial blood pressure • Heart rate greater than predicted maximum heart rate • Change in cardiac rhythm on the cardiac monitor • Increased accessory muscle use with increased work of breathing • Increase in respiratory rate of 20 breaths/minute from baseline • Extreme fatigue or pallor • Patient requests to stop

Adler et al (2012) • Systematic Review • Notes inherent complication to mobilizing patients are not straight forward or well established • Tenuous hemodynamics • Severe weakness • Multiple central catheters and life supporting monitors • Artificial airways • Operational factors • Few randomized control trials performed

Adler et al (2012) cont. • 10 studies reported data regarding adverse events and physiological changes • Adverse events occurred in less than 4% • Oxygen desaturation common • Accidental removal of patient support equipment occurred in less than 1% of total patient cases

Baily et al (2007) • Sacket level 4 • Early activity in all respiratory failure patients who required mechanical ventilation > 4 days in the respiratory ICU • RICU staff consisted of RN, RT, PT, and critical care techs who provided twice daily activity on patient’s that had to be able to participate • No heavy sedation or coma • Maintains blood pressure upright • Maintains adequate oxygen saturation • Activity Events • Bed exercises, EOB sitting, Transfers, and ambulation • 1, 449 activity events on 103 patients

Baily et al (2007) cont. • Adverse events • Fall to knees without injury • Feeding tube removal • Systolic blood pressure > 200 mmHg or diastolic < 90 mmHg • Desaturation < 80 % • < 1% of activity related adverse events • No patient extubated during activity • Note: Patients with endotracheal tube in place = 593 events • 42% of which were ambulation

Morris et al (2008) • Prospective cohort study • Sackett Level 2b • Mobilization program implemented 7 days/week by the “mobility team” • Consisted of PT, RN, and nurse assistant • N= 330 • 165 intervention group • 165 “usual” care • 638 PT sessions • No serious adverse medial consequences • Mobility sessions primarily ended due to c/o fatigue

Stiller et al (2004) • Prospective study • One group pre-test/ post-test design • Sacket level 4 • N= 160 with 31 patients receiving mobilization post screening • PT interventions • Supine<-> sit, sitting EOB, standing, transfers, and ambulation • Total 69 mobility sessions with 31 patients • 3 adverse events (4%) during PT treatment • Desaturation of O2 < 88%

Garzon-Serrano et al (2011) • Across the U.S. 89% of PTs require a PT consult to initiate mobilization in the ICU • Data shows that patients who were transferred to an ICU where early mobility was a priority demonstrated increased ability to ambulate at discharge compared to those patients who were cared for in an ICU without early mobility. • 20 bed SICU at MGH • 63 patients with PTs and RNs performing 179 sessions • 4 point numerical scale: • Bed mobility, EOB, transfers to chair, and gait

Garzon-Serrano et al (2011) cont. • Found that patient’s level of mobilization achieved by physical therapists was significantly higher than those achieved by nurses • Barriers varied • PT • Neurologic impairments • Nurses • Hemodynamic instability and renal replacement therapy • No adverse events were observed with mobilization by RNs or PTs

Pohlman et al (2010) • Descriptive analysis of intervention arm of the study by Schweickert et al. • Mechanically ventilated patients in a medical ICU • Daily sedation holidays followed by PT/OT • PT/OT consisted of: 498 activity events • AROM • ADLs • Sitting • Standing • Walking as tolerated • PT/OT was started at 1.4 days after intubation and was provided 90% of MICU days

Pohlman et al (2010) cont. • 69% of patients achieved edge of bed (EOB) • 33% of patients achieved bed to chair • 15% of patients achieved ambulation (15-20 ft.) • Adverse Events • 16 % (80 of 498) • Expected physiologic changes with exercises • HR > 20 % baseline (21 of 498) • RR> 40/min (20 of 498) • Most common O2 desaturation (short duration) but did not require life sustaining events • Found feasible with adverse events uncommon during endotracheal intubation

Outcomes

Baily et al (2007) • As discussed above • 103 patient with respiratory failure • Recorded 1449 activity events • 233 Sitting Edge of Bed • 454 Sitting in Chair • 762 Ambulation • Many patients with Endotracheal tube in place and still able to ambulate

Baily et al (2007) cont. • Conclusions: • Feasible and safe • Cited study by Martin et al where 100% of patients were bedridden at ICU discharge • Baily’s study with focus on early activity lead to over 75% able to reach highest activity level of ambulation prior to RICU discharge • 69% were able to ambulate >100 feet

Baily et al (2007) cont. • Increased # of comorbidities did not increase the time until patient was able to ambulate

Baily et al (2007) cont. • “Early activity is a candidate therapy to prevent or treat the neuromuscular complications of critical illness”

Morris et al (2008) • As discussed above • Prospective cohort study • Mobilization program implemented 7 days/week by the “mobility team”of PT, RN, and nurse assistant • 165 intervention group vs. 165 “usual” care • 638 PT sessions

Morris et all (2011) • Mobility Protocol Patients were: • Out of bed earlier • Had therapy initiated more frequently in the ICU • Decreased ICU length of stay • Decreased hospital length of stay

Burtin et al (2009) • Prospective study • Sacket level 2B • Critically ill patients in medical and surgical ICUs • N= 90 enrolled with 67 completing the study • 36 in control group, 36 in treatment group • Both Groups: 5d/wk, UE ther ex, LE ther ex, functional training • Treatment Group: cycling session 20min total/day • Total 425 PT cycling sessions with 31 patients • No severe adverse events • <4% with early termination due to changes in vitals

Burtin et al (2009) • Training Group: • Increased ability to perform 6 min walk test • Increased quad force • Higher self perceived functional status • At hospital discharge • 55% of control group could walk independently • 75% of treatment group could walk independently • Small but not significant difference in LOS • 17% referred to rehab center compared to 10% of treatment group

Needham et al (2010) • Prospective quality improvement project • N= 57 patients mechanically ventilated for 4 days or longer • Multidisciplinary team implemented to: • reduce heavy sedation • increase staffing to include full time PT & OT • new OT/PT consultation guidelines

Needham et al (2010) • Outcomes: • Decreased use of sedatives • Increased alertness and decreased delirium • Increased % of patient engaged in more advanced mobility activities • Increased number of PT/OT consults and interventions • Decreased ICU and hospital LOS

Malkoc et al (2009) • 510 mechanically ventilated patients in medical ICU of a university hospital • standard care group vs. treatment group • Treatment group: chest PT program • modified postural drainage, percussion, vibration, coughing, simulation techniques, deep breathing exercises, suctioning, bed exercises and mobilization 2x/d, 5d/wk • Results: • Control group had longer period of ventilator dependency than treatment group

Schweickert et al (2009) • Assessed efficacy of combining daily interruption of sedation with physical and occupational therapy on functional outcomes • N=104 • Control (n=55) daily sedation without therapies • Intervention (n=49) daily interruption of sedation with therapy

Schweickert et al (2009) • Results: • 59% of intervention group vs. only 35% of control group was able to return to independent functional status at hospital d/c • Intervention group had more ventilator-free days • Intervention group had shorter duration of delirium

Population Specific Studies

Post Acute MICortes et al (2009) • Systematic Review and Meta-analysis • 14 studies included • Comparing early mobilization to a control/standard treatment • Reported data on mortality and non-fatal re-infarction • Results: • 82 vs. 80 non-fatal re-infarctions in treatment vs. control groups • Decreased mortality 149 deaths in the treatment group and 179 deaths in control group

PA and Femoral CathetersWinkelman et al (2011) • An “Ask the Expert” article in Critical Care Nurse

PA and Femoral CathetersWinkelman et al (2011) • Pulmonary Artery Catheters • Insufficient data to build a standard or policy • Most reports of complications focus events during insertion not events associated with patients’ movements or activity • Indirect evidence suggests that sitting in a chair, standing and walking occur in practice and research settings • No adverse outcomes specific to mobilizing patients who have a PA catheter were reported in any of those studies

PA and Femoral CathetersWinkelman et al (2011) • Femoral Catheters • Retrospective chart review details no adverse events among 20 cardiovascular surgery patients • Several studies of healthy adults participating in sitting, standing, repetitive and resistance exercise in lab settings with no major complications

Obese PatientsGenc et al (2012) • Study looked at mobilization on respiratory and hemodynamic parameters in critically ill obese patients • ( N= 31) 37 mobilization sessions in 31 obese patients • Conclusion • early mobility in the ICU promotes respiratory reserve in obese pts. • early mobility is safe if cardiorespiratory parameters are measured

Patients on ECMOLowman et al (2012) • Case Presentation • 16 y/o girl with severe acute respiratory failure due to CF exacerbation on ECMO • Received PT: exercise, manual therapy, integumentary protect techniques, and airway clearance • Found that PT interventions, including out of bed mobility, can be safely provided to patient on portable ECMO (veno-venous ECMO) as a bridge to lung transplantation

Patients Post Left Ventricular Assist Device (LVAD) ImplantationPerme et al (2006) • Case Report • 51 y/o male with heart failure due to dilated cardiomyopathy who underwent VAD implant and R lower lobe resection of pulmonary granuloma • PT starting POD 7: LE strengthening, mobility ( edge of bed, standing, bed to chair, gait training, and hallway ambulation) • Patient showed substantial functional gains during the period of prolonged mechanical ventilation • Noted that patient’s medical condition never deteriorated as a direct result of the physical therapy interventions

References • Adler, Joseph, and Daniel Malone. “Early Mobilization in the Intensive Care Unit: A Systematic Review.” Cardiopulmonary Physical Therapy Journal 23.1 (2012): 5-13. Print. • Bailey, Polly, George E. Thomsen, Vicki J. Spuhler, Robert Blair, James Jewkes, Louise Bezdjian, Kristy Veale, Larissa Rodriquez, and Ramona O. Hopkins. “Early Activity Is Feasible and Safe in Respiratory Failure Patients” Critical Care Medicine 35.1 (2007): 139-45. Print. • Burtin, Chris, Beatrix, Clerckx, Christophe Robbeets, Patrick Ferdinande, Daiel Langer, Thierry Troosters, Greet Hermans, Marc Decramer, and Rik Gosselink. “Early Exercise in Critically Ill Patients Enhances Short-term Functional Recovery*.” Critical Care Medicine 37.9 (2009)2499-505. Print. • Cortes, Olga L., Juan C. Villar, P.J. Devereaux, and Alba DiCenso. “Early Mobilization for Patients following Acute Myocardiac Infarctions: A Systematic Reivew and Meta-analysis of Experimental Studies.” International Journal o Nursing Studies 46.11 (2009): 1496-504. Print. • Desai, Sanjay V., Tyler J. Law, and Dale M. Needham. “Long-term Complications of Critical Care.” Critical Care Medicine 39.2 (2011): 1. Print. • Garzon-Serrano, Cheryl Ryan, Karen Waak, Ronald Hirschberg, Susan Tully, Edward A. Bittner, Daniel W. Chipman, Ulrich Schmidt, Georgios Kasotakis, John Benjamin, Ross Zafonte, Matthias Eikermann. “Early Mobilization in Critically Ill Patients: Patients’ Mobilization Level Depends on Health care Provider’s Profession.” American Academy of Physical Medicine and Rehabilitation 3 (2011): 307-13. Print.

References • Genc, Arzu, Seher Ozyurek, Ugur Koca, and Ali Gunerli. “Respiratory and Hemodynamic Responses to Mobilization of Critically Ill Obese Patients.” Cardiopulmonary Physical Therapy 23.1 (2012): 14-18. Print. • Gosselink, R., J.Bott, M. Johnson, E. Dean, S.Nava, M. Norrenberg, B. Schonhofer, K. Stiller, H. Leur, and J. L. Vincent. “Physiotherapy for Adult Patients with Critical Illness: Recommendation of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients.” Intensive Care Medicine 34.7 (2008): 1188-199. Print. • Lowman, John D., Tamara K. Kirk, and Diane E. Clark. “Physical Therapy Management of a Patient on Portable Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation: A Case Report.” Cardiopulmonary Physical Therapy Journal 23.1 (2012): 30-35. Print. • Malkoc, Mehtap, Didem Karadibak, and Yucel Yldrm. “The Effect of Physiotherapy on Ventilatory Dependency and the Length of Stay in an Intensive Care Unit.” Journal of Rehabilitation Research 32.1 (2009): 85-88. Print. • Morris, Peter E., Amanda Goad, Clifton Thompson, Karen Taylor, Bethany Harry, Leah Passmore, Amelia Ross, Luara Anderson, Shirley Baker, Mary Sanchez, Lauretta Penley, April Howard, Luz Dixon, Susan Leach, Ronald Small, R.Duncan Hite, and Edward Haponik. “Early Intensive Care Unity Mobility Therapy in the treatment of Acute Respiratory Failure*.” Critical Care Medicine 36.8 (2008): 2238-243. Print.

References • Needham, Dale M., Radha Korupolu, Jennifer M. Zanni, Pranoti Pradhan, Elizabeth Colantuoni, Jeffrey B. Palmer, Roy G. Brower, and Eddy Fan. “Early Physical Medicine and Rehabilitation for Patients With Acute Respiratory Failure: A Quality Improvement Project.” Archives of Physical Medicine and Rehabilitation 91.4 (2010): 536-42. Print. • Perme, C., and R. Chandrashekar. “Early Mobility and Walking Program for Patients in Intensive Care Units: Creating a Standard of Care.” American Journal of Critical Care 18.3 (2009): 212-21. Print. • Pohlman, Mark C., William D, Schweickert, Anne S. Pohlman, Celerina Nigos, Amy J. Pawlik, Cheryl L. Esbrook, Linda Spears, Megan Miller, Mietka Franczyk, Deanna Deprizio, Gregory A. Schmidt, Amy Bowman, Rohnda Barr, Kathryn McCallister, Jesse B. Hall, and John P. Kress. “Feasibility of Physical and Occupational Therapy Beginning from Initiation of Mechanical Ventilation*.” Critical Care Medicine 38.11 (2010): 2089-094. Print. • Schwickert, William D., Mark C. Pohlman, Anne S. Pohlman, Celerina Nigos, Amy J. Pawlik, Cheryl L. Esbrook, Linda Spears, Megan Miller, Mietka Franczyk, Deanna Deprizio, Gregory A. Schmidt, Amy Bowman, Rohnda Barr, Kathryn E. McCallister, Jesse B. Hall, and John P. Kress. Early Physical and Occupational Therapy in Mechanically Ventilated, Critically Ill Patients: A Randomized Controlled Trial.” The Lancet 373.9678 (2009): 1874-882. Print.

References • Stiller, Katy, Anna Phillips, and Paul Lamber. “The Safety of Mobilisation and Its Effect on Haemodynamic and Respiratory Status of Intensive Care Patients.” Physiotherapy Theory and Practice 20.3 (2004): 175-85. Print. • Perme, Christiane S., Robert E. Southard, David L. Joyce, George P. Noon, and Matthias Loebe. “Early Mobilization of LVAD Recipients: Who Require Prolonged Mechanical Ventilation.” Texas Heart Institute Journal 33.2 (2006): 130-33. Print. • Vollman, Kathleen M., “Progressive Mobility in the Critically Ill: Introduction to Progressive Mobility.” Critical Care Nurse 30.2 (2010). Print. • Winkelman, Chris. “Ambulation With Pulmonary Artery or Femoral Catheters in Place.” Ccn.aacnjournals.org. Critical Care Nurse, Oct. 2011. Web. Oct. 2011 • Zanni, Jennifer M., and Dale M. Needham. “Promoting Early Mobility and Rehabilitation in the Intensive Care Unit.” Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital (2010): n. pag. Print.

Evidence Based Practice: A Comprehensive Literature Review on Early Mobility