Rehabilitation of patients in critical care settings

Author(s): Diane Schretzman Mortimer, MD, James Dvorak, MD, Parisa Salehi, MD, Vasilios Kountis, DO

Originally published:10/02/2015

Last updated:10/02/2015

1. DISEASE/DISORDER

Definition

Hospitalization in an intensive care unit (ICU) can be associated with a perilous functional decline.1 Patients can develop impairments in mobility, cognition, and ability to perform activities of daily living (ADL).2 This frequent complication is associated with longer time on mechanical ventilation, longer ICU stay, and increased overall mortality.3

There is not a consistent nomenclature for this functional decline. ICU acquired weakness (ICUAW) and critical care neuromyopathy (CCN) are commonly used but vague terms. Critical illness myopathy (CIM) and critical illness polyneuropathy (CIP) refer to specific conditions.4,5

Diagnostic criteria have not been firmly established. Patients are heterogeneous in their underlying disease process, presentation, and course. Diagnosis is largely based on clinical examination and careful interpretation of findings. Conventional measures, such as mental status, manual muscle strength testing, balance, and mobility evaluations, are often affected by critical illness and its treatment. Supporting data, including laboratory tests and electrodiagnostic testing, are helpful but do not produce uniform results.6,7

Etiology

Factors contributing to critical care patients’ functional decline include the primary illness and its severity, as well as interventions like mechanical ventilation and sedation. Patients can develop metabolic derangements, such as hyperglycemia and acute stress phenomena, which affect muscles and nerves. The ICU environment, which is often highly stimulating while involving prolonged bedrest and immobility, is itself problematic. Disturbed sleep, inadequate nutritional intake, and pain are also culprits.1,2,4,5,8,9

Epidemiology

Muscle weakness, ranging from mild limb paresis to severe tetraplegia, has been noted in up to 25% of all patients who spend seven or more days in an ICU.3 The incidence of weakness appears to rise sharply with acute respiratory failure and higher severity of critical illness. Weakness has been reported in up to 60% of patients who undergo more than one week of mechanical ventilation.3,4 and up to 70% of patients diagnosed with sepsis or systemic inflammatory response syndrome. The incidence approaches 100% if multiple organ failure is present.3

Patho-anatomy/ physiology

ICU patients are often on bedrest to conserve metabolic resources, due to machines and lines, and for comfort. Complications of bedrest include disuse muscle atrophy, joint contracture, thromboembolic disease, insulin resistance, atelectasis, and skin breakdown.2,10Bedrest also causes loss of mechanical loading on joints and muscles.11

Immobility in the setting of critical illness has deleterious effects on muscle structure and function. Experimental models of prolonged immobility demonstrate a muscle mass decrease of 1.5 to 2 percent during the first 3 weeks of strictly enforced rest. Weight-bearing muscles of the lower limbs and core are particularly affected by this diminished mass. The loss of muscle mass is primarily due to reduced size of fibers. Proteins are degraded by multiple pathways in the setting of both activity and stress. The decrease in muscle mass and fiber size results in loss of strength. Muscle strength can decrease by as much as 15% after 2 weeks of bedrest and by more than 50% after 28 days of forced limb immobilization.10

Sepsis and other critical illnesses induce metabolic and vascular derangements that damage peripheral nerves and skeletal muscles. Pathophysiological factors, including microvascular changes, increased membrane permeability, alterations in electrical potentials and conductivity, and cellular inflammation, coalesce and instigate precarious sequelae. Peripheral nerves experience subsequent damage that functionally approximates demyelination and axon degradation. In muscles, metabolic changes lead to decreased contractility and increased catabolism.4,9,10,11

Acute respiratory failure requiring mechanical ventilation is also associated with the development of weakness.12 Prolonged mechanical ventilation can alter diaphragmatic structure and function, leading to difficulties with both breathing and ventilator weaning.13

Medications commonly used in the ICU can inadvertently cause weakness. These include neuromuscular blockers, steroids, and sedatives. Neuromuscular blockers can damage the neuromuscular junction and its functioning. Steroids can both injure muscle cells and affect muscle and nerve metabolism. Sedatives can lead to decreased muscle contraction and vascular tone, and altered mobility in the setting of sedation.3,6,7

Malnutrition in the setting of critical illness may also contribute to neuromuscular dysfunction. Weight loss may reflect abnormalities in fluid and nutritional status. The administration of artificial nutrition, with sufficient calories, protein, and fat, improves energy and protein intake. Optimizing nutrition, and stabilizing body weight, are mainstays of ICU care. Current standard clinical practice includes providing enteral feeding as soon as possible and avoiding prolonged interruptions in feeding. Although adequate nutrition has not been definitively shown to prevent muscle atrophy or subsequent weakness in critically ill patients, malnutrition has been determined to be detrimental. Therefore, nutrition should be optimized as part of a comprehensive strategy to treat these patients.9,14,15

Disease progression

The onset is often insidious. Patients generally initially exhibit either focal or generalized weakness. Subtle muscle and functional changes often go unnoticed since detailed assessments of motor function are not the priority in critical situations. The first observed signs are often generalized muscle atrophy or difficulty with ventilator weaning. Later, limbs are flaccid, with weakness affecting lower limbs more than uppers. Some patients progress to quadriparesis. Facial weakness and ophthalmoplegia can occur, but head, facial, tongue and jaw movements tend to be spared.3,16

In cases of critical illness polyneuropathy (CIP), patients can lose distal pain, temperature and vibratory sensation. Reflexes are often diminished or absent. In critical illness myopathy (CIM), reflexes may be normal or diminished, but are present.7,9,16,17

Symptom progression and severity vary among individuals. Observable declines in muscle size and function have been detected after just 2 weeks of immobility. Alterations in peripheral nerves are also clinically evident within 1 to 2 weeks of critical illness.10,11 Evolution to extensive and generalized atrophy can occur over subsequent weeks to months. The timeline is uncertain, but more severe and persisting symptoms correlate with lengthier and more intense exposure to hazards like immobility, sepsis and other critical illness, mechanical ventilation, and offender medications.3

Recovery is also variable. While exact numbers are unknown, it is clear that many patients recuperate following their critical illness. However, at least some patients with severe illness do not make a full recovery.3,9 In fact, at least 50% of ICU patients report inability to return to work due to fatigue, weakness, and overall impaired functional status one year after their critical care stay.1

Specific secondary or associated conditions and complications

The functional decline is associated with increased burden and cost of care over the short and long term. This problem is associated with longer stays in the ICU and acute care and higher likelihood of discharge to a nursing home or other care facility.1,3,18,19

Functional decline puts patients at risk of additional complications. Affected patients experience increased medical complications and decreased ability to recover independence with activities of daily living. Patients also report development of chronic issues with persistent weakness, poor exercise tolerance, and ongoing disability.1,5,9

Other consequences include delirium, impaired cognition, and mental health conditions. Patients may develop delirium while in the ICU. Following the critical care stay, some cognitive impairments may persist.5 More than 15% of ICU patients later report symptoms consistent with anxiety or even post-traumatic stress. These symptoms may be rooted in issues related to the illness or trauma that led to ICU stay, critical care treatment or environmental issues, or medications.20,21

Post-ICU syndrome is an inconsistently defined entity encompassing cognitive and emotional difficulties that patients may experience in the months and years following their critical care stay. These issues have the potential to negatively impact quality of life. It is not clear how many patients are affected. In some small studies, it seems to correlate with more severe respiratory distress syndrome, sepsis, and overall illness while in the ICU. Treatment includes addressing the symptoms. Patients generally improve over time.20,21

2. ESSENTIALS OF ASSESSMENT

History

Prior functional status includes previous level of independence, health history, prior musculoskeletal or skin issues, and substance abuse history.

The ICU course is very important. This includes diagnosis that led to ICU stay, severity of illness, treatment course including potential need for steroids, vasopressors, mechanical ventilation, systemic antibiotics, and mechanical ventilation, and the presence of metabolic derangements such as hyperglycemia.6,7

Physical examination

Vital signs: any instability, orthostasis, hyperthermia/fever or other abnormalities.

Neurological: mental status including level of consciousness and brief cognitive screen; cranial nerves including brainstem function; motor, including tone and strength; sensory, including light touch, sharp/ dull, proprioception, and vibratory sense; coordination, station and gait; and muscle stretch reflexes.

Musculoskeletal: joint range of motion to identify possible contractures and muscle bulk to identify atrophy.

Skin: evaluate any healing incisions or wounds.6,7,16

Clinical functional assessment

Current functional status assessment should include swallowing, speech and cognition; self-care; mobility and functional activity tolerance. The six minute walk test, which measures the distance an individual can ambulate in that timeframe, is one standard measure of function.6

The Perme ICU Mobility Score is an ICU-specific tool that evaluates ambulation and mobility. Its high reliability among clinicians makes it useful. Assessment categories include mental status, potential mobility barriers, functional strength, bed mobility, transfers, gait, and endurance. Lower scores indicate that more assistance is needed to facilitate mobility.22

Additional items to evaluate include ambulation abilities, gait and balance, sleep, pain, and nutrition.6,23,24

Laboratory studies

-Metabolic panel including electrolytes, glucose, renal, and liver studies.
-Complete blood count including white blood cell count and hemoglobin.
-Creatinine kinase.7,16
-Albumin and pre-albumin levels.14
-Endocrine tests including thyroid function may reveal causes of weakness. Cortisol tests, which can help expose corticosteroid insufficiency, include a stress cortisol level, which is a random total serum cortisol. The delta cortisol, or the change in the serum cortisol in response to 250 mcg of synthetic adrenocorticotropic hormone (Cosyntropin), and the free cortisol level, are also important parts of the evaluation.25

Imaging

Chest imaging can reveal pulmonary abnormalities that may be contributing to poor ventilator weaning.

Brain and/or spinal cord imaging may demonstrate central nervous system etiologies for weakness.16,26

Supplemental assessment tools

Electrodiagnostic (Edx) testing: The most common reasons for Edx testing in ICU patients are unexpected failure of ventilator weaning and generalized weakness. Edx can help distinguish between diagnostic possibilities such as critical illness myopathy (CIM), critical illness polyneuropathy (CIP), an undiagnosed neuromuscular disorder, or another systemic illness. Less common etiologies, including phrenic nerve injuries, cervical cord lesions, mononeuropathies and plexopathies, are also revealed.16,17

Two of the neuromuscular disorders most often diagnosed in critically ill patients are CIM, which affects skeletal muscles, and CIP, which affects peripheral nerves. In CIM, nerve conduction studies (NCS) demonstrate normal or near normal conduction velocities, normal sensory nerve action potentials (SNAPs), and normal or low amplitude compound muscle action potentials (CMAPs). Electroymyography (EMG) demonstrates low amplitude, frequent motor units and abnormal/ increased insertional activity. In CIP, NCS reveal normal or near normal conduction velocities, reduced SNAP amplitudes, and reduced CMAP amplitudes. EMG demonstrates fibrillations and positive sharp waves, consistent with widespread denervation. There is also often overlap between these disorders.3,7,16,17

The optimal timing of Edx testing has not been determined. An estimated 85% of patients who spend seven days in an ICU exhibit detectable muscle abnormalities on electromyography (EMG),3 but these abnormalities do not necessarily affect function. Edx testing should be obtained when otherwise unexplained difficulties with ventilator weaning or weakness are affecting a patient’s progress.16,17

Early prediction of outcomes

Factors that are associated with poorer functional outcomes include neurological and cognitive impairments, severe mobility impairment, higher severity of critical illness, multiple active and ongoing medical co-morbidities, persistent sleep deprivation, and the lack of a support system. Protective factors have not yet been determined.3,18,23

Environmental

The ICU environment, including levels of noise, natural light, and family involvement, should be explored.23

Social role and support system

A psychosocial assessment evaluates how the current illness impacts the patient’s life, support system, and role in society. Available family and community resources and supports are also assessed.27

Professional issues

It is important to maintain appropriate and timely dialogue with the patient, family, and critical care teams regarding the patient’s goals and preferences for care; the patient’s ability and willingness to participate in rehabilitation interventions; and expected functional outcomes.8,24

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

Functional decline among ICU patients is at least partially preventable via early mobilization and rehabilitation interventions during the critical care stay, even in extremely ill patients. In fact, early and intensive intervention by physiatrists and other rehabilitation clinicians can prevent or reduce the development of weakness.1,3,4,10,26,28,29

These rehabilitation interventions decrease time in bed, decrease ICU and hospital lengths of stay, improve functional outcomes, and increase rates of discharge to home.18,26,29,30,31More than 25% of adults who experience functional decline in critical care units require long term care after hospital discharge.18 A small study of early mobilization demonstrated lowering the rate of discharge to nursing home or long term acute care facility by nearly 20%.19 Since there is no net increase in expense associated with these interventions, implementing them leads to lower hospital resource use and overall cost.3,12,30

Given these many benefits, it is clear that an interdisciplinary protocol, facilitating the safe and early mobility of ICU patients with respiratory failure and other critical issues, must be implemented.3

Additional interventions aimed at preventing or minimizing functional decline involve optimizing the metabolic state. Hyperglycemia should be minimized using ICU intensive insulin therapy protocols.9 Nutrition and sleep should be optimized.14,23 Sepsis and multiple organ failure should be aggressively avoided and rapidly treated.9,11 The benefits and risks of high ventilator settings, deep sedation, and steroids should be carefully considered prior to their use.4

At different disease states

Rehabilitation interventions are initiated during the acute phase of the critical illness, even before the patient is able to actively participate. An activity and mobility program is safely started when the patient is stable from a hemodynamic perspective.5 Positioning, splinting, passive stretching, and range of motion exercises prevent contractures and preserve muscle length and mass.10,32 Transferring patients from their beds to upright seated devices maintains function of core muscles and vascular structures.2,13,32

When the patient is able to participate, isometric and resistance exercises are implemented. General strengthening programs, including low intensity resistance exercises, preserve muscle anabolic activity and prevent atrophy. Strengthening programs also address diaphragm weakness after mechanical ventilation, since this weakness is likely rooted in contractile dysfunction. Trials of assisted ambulation positively affect musculoskeletal, cardiovascular, pulmonary, skin and emotional performance.2,12,13,32

Therapy programs are individualized. Therapists and other team members assess patients’ physiological responses to the activities. These responses guide the nature, intensity, and duration of subsequent therapy sessions. Therapies should be provided at least daily, and multiple short sessions can be provided during the day, as tolerated. 19,24,32

Early rehabilitation is also indicated for patients with specific diseases. For instance, the early initiation of therapies for acute stroke patients improves post-stroke recovery and overall outcomes. Similar findings have been demonstrated for patients in the critical care phases of burn, traumatic brain injury, and spinal cord injury.33,34

After the ICU course is completed, patients continue therapy interventions to optimize overall function. Individualized, goal-focused rehabilitation programs progress throughout the hospital stay and next steps in care.1,2,19,26

Coordination of care

There are multiple obstacles to mobilizing ICU patients. Nursing and rehabilitation staff members may have concerns regarding patient safety or physiologic stability. There may be risk of dislodging crucial devices. Additional barriers may include the amount of sedation a patient requires, ventilator settings that preclude much movement, and medical or vascular access devices inserted in sites that prevent mobility.1,5,12

Other impediments to early mobility in ICU have been examined. Nurses and rehabilitation therapists may not have sufficient knowledge or comfort levels or there may be insufficient equipment, time, or staff to safely engage in these interventions.1,5,8

Consulting physiatrists help address these hurdles by collaborating with the ICU medical, nursing, and rehabilitation team to facilitate the development and implementation of an early mobility protocol. Physiatrists work with the interdisciplinary team to procure equipment and educate staff members. These practices cultivate a very culture that favors early rehabilitation over time.1,5,8,24

Patient and family education

Patients and families are included in discussions regarding rehabilitation interventions. Rationales for the protocol are shared. Families learn and provide basic range of motion techniques. Patients undergo education prior to mobility and ambulation procedures. Patients and families should be permitted to provide valuable feedback regarding their experiences with early mobility interventions.2,24

Patients and families need regular updates about the patient’s condition and status. The ICU interventions are explained in appropriate detail. It is possible that this education will help families and patients process this information during the ICU stay and may help prevent or lessen anxiety symptoms later.20,21

Measurement of treatment outcomes

It is important to evaluate outcomes in critically ill patients participating in early mobility protocols. At this time, however, there is not one robust outcome statistic. Clinicians follow strength, mobility, and overall functional status over short and long-term periods. One useful measure is extremity muscle strength, by hand-held dynamometry or manual muscle testing. Monitoring ambulation distance or timed mobility tests are also worthwhile. Functional assessments, such as Barthel Activities of Daily Living Index and Functional Independence Measures (FIM) provide essential information as well. The Functional Status Score in the ICU, which consists of selected FIM items, also communicates helpful information about these patients.28

Translation into Practice

There is ample evidence supporting the mobilization and rehabilitation of critically ill patients.2,3,12,19,24,26,27,29,30,31,32,34,35,36 However, these interventions are exceedingly difficult to implement into clinical practice due to the presence of inherent barriers. A collaborative interdisciplinary program, including a safe protocol, is needed to overcome these obstacles.1,5,8,24,32,37

Physiatrists help champion an ICU culture that promotes early mobility. The interdisciplinary team continuously optimizes outcomes by evaluating practices that interfere with early mobility, creating strategies to allow mobility, and implementing short and long term plans.8,24,37

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

Other physical medicine and rehabilitation interventions prevent and treat ICU acquired weakness. Neuromuscular electrical stimulation (NMES), where electrical current is delivered transdermally to stimulate a muscle to contract, preserves muscle length and function, even when the muscle is not being voluntarily activated. NMES has also been shown to have beneficial effects on the inflammatory cascade and circulatory function.10,38

Cycle ergometry is a stationary cycling apparatus that has a mechanism to alter the amount of work done by the person who is exercising. It can provide passive, active-assisted, or active range of motion exercises for either upper or lower limbs. Use of this device maintains structure and function in patients with critical illness.5,38

Interactive video games are being trialed as part of rehabilitation in ICU patients. These enjoyable games have been shown to improve balance and endurance. In some games, patients stand and ambulate. Use of the games is generally safe and feasible in most critically ill patients, even those who are on mechanical ventilators.39

Custom designed technological aids help with safety and effectiveness of early mobilization, particularly for patients on mechanical ventilators. Specially designed walkers, chairs, and standing frames hold multiple pieces of ICU equipment, facilitate standing and walking activities, and optimize balance.38

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Controversies and gaps in the evidence-based knowledge

Current practice includes sedation for most ICU patients. This sedation may be putting patients at risk for functional decline. Future approaches to ICU patients, particularly those at high risk for delirium or on a mechanical ventilator, may include avoiding sedation. Of course, this would require a significant change in the ICU environment and staffing patterns, since patients without sedation would likely be in need of more supervision, interaction, and monitoring for safety and comfort.8

Some researchers advocate development of new ways to treat patients with respiratory failure. Current mechanical ventilator settings have the potential to injure the lungs and diaphragm with prolonged use. It is possible that in the future additional modalities may replace mechanical ventilation as it is currently known.13

It is not certain whether certain nutrients or antioxidants given during the critical illness may help prevent functional decline. Arginine, glutamine, and fish oil supplementation have not demonstrated conclusive benefits yet. More studies are needed.11,14

Finally, outcomes in ICU patients who participate in mobility programs should be compared with similar ICU patients who do not participate in a mobility program. It would be helpful to have a specific outcome measure, either biometric or qualitative, to optimally evaluate and delineate the effects of an early mobility program.6,28

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Author Disclosure

Diane Schretzman Mortimer, MD
Nothing to Disclose

James Dvorak, MD
Nothing to Disclose

Parisa Salehi, MD
Nothing to Disclose

Vasilios Kountis, DO
Nothing to Disclose

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