For 3 weeks I was held in a room, I was tied to the bed if I tried to get away. I couldn’t talk; I couldn’t eat; I was not allowed to sleep;
Groups of people would enter the room and look at me and talk about me and I was sometimes undressed in front a small audience.
I was shot full of drugs.
I was too weak to move.
I could not see my body, but it had been cut nearly in half.
Insects crawled on the walls and ceilings…

Sound like prison or torture? Well, it’s not. The quote is from Nancy Andrews, a survivor of critical illness who developed delirium . And, an articulate spokeswomen regarding ICU sequelae, specifically delirium, from a survivors perspective.

Now, to be fair, I am already bias. I treat primarily in ICU’s (medical, cardiac, and step down units). I also treated in the treatment arm of a randomized control trial of early, intensive physical therapy for individuals requiring mechanical ventilation for greater than 4 days. The treatment group received physical therapy 7 days a week for at least 30-60 minutes. And, I participate in research surrounding ICU physical therapy. Oh, I am also a physical therapist. So, don’t take my word for it…

But, the curse of bed rest needs to end.  In 1966 “The Dallas Bed Rest Study” put five 20 year old males to bed for three weeks. Investigators conducted pre and post testing followed by exercise training and long term follow ups (30 and 40 years). The acute effects of the bed rest and long term outcomes are staggering. Net proportional decline in VO(2 max) over 40 years was comparable to that experienced after 3 weeks of strict bed rest (27% vs. 26%). Additionally, 40% of age related decline in maximal oxygen uptake could be attributed to physical inactivity specifically. Three weeks of bed rest at 20 years of age resulted in a more profound impact on physical work capacity than 30 years of aging.

Unfortunately, each day of bed rest in the ICU may predict a 3 to 11% strength decline up to 2 years later. During a 2 year investigation, the length of bed rest was consistently associated with measures of weakness at all time points. The presence of weakness correlated to decreased physical function and quality of life.

The Legacy of Critical Illness

So, why are we talking about this? It has been well established that individuals who survive critical illness requiring mechanical ventilation specifically acute respiratory distress syndrome exhibit muscle weakness, persistent physical disability, and impaired reports regarding quality of life (via the SF-36) after hospital discharge. After 5 years, with an impressive 86% follow up rate, only 75% returned to work and subjects utilized 4 times the healthcare costs (86% follow up rate).

Sequelae of the ICU

The phenomena of ICU-Acquired Weakness (ICU-AW) and it’s specific subsets critical illness polyneuropathy (CIP) and critical illness myopathy (CIM) have been characterized. Following merely 18 hours of mechanical ventilation structural and functional changes in the diaphragm muscular are present. Those who require prolonged mechanical ventilation are worse off still. Some exhibit global electrophyisologic abnormalities consistent with neuropathy and myopathy in conjunction with weakness 5 years post ICU discharge. Many complain of persistent weakness, disability, and a prolonged recovery period.

Dr. Margaret Herridge, MD, MPH comments:

This is a huge public health catastrophe when we’re saving people’s lives but they’re ending up with severe disability. It’s a very important message for patients, families and primary care physicians because I think patients assume they should be well, so they feel bad that they aren’t.

Sadly, the sequelae of critical illness extend beyond physiologic abnormalities of nerves and muscles, weakness, and physical function. Survivors display significant neuro-cognitive problems. At one year follow up of 821 medical and surgical ICU patients more than 50% displayed memory and attention deficits. The presence of post-traumatic stress and post-traumatic stress syndrome are now well recognized. At 1, 2, and 5 years post ICU discharge reports of depression and anxiety persist in nearly 50% of some studied cohorts. Survivors suffer not merely from physiologic and physical impairments, but significant and quite limiting neuro-cognitive deficits in conjunction with psychological difficulties.

What happened to me in the hospital?   Yes, my life was saved, and I am grateful for that, but life AFTER the ICU was extraordinarily difficult, not only physically but also mentally. -Nancy Andrews

Factors associated with long term physical impairments include duration of bed rest, age, ICU length of stay, and potentially the dosage corticosteroids.  Amount and duration of sedation, development of delirium, and delusional memories are associated with long term neurocognitive impairments.

And, unfortunately it doesn’t end with the patient. Family members and caregivers of ICU patients exhibit mental health difficulties including anxiety, depression, PTSD, and complicated grief following the intensive care experience. Recently, Post Intensive Care Syndrome (PICS) was constructed to assist in recognition and classification of survivors’ as well as family members’ post ICU impairments. The goal, of course, is to improve outcomes following critical illness.

Physical Therapy IN the ICU?

The focus surrounding early mobilization of critically ill, mechanically ventilated patients as well as physical therapists involvement in the ICU continues to grow. Although by no means complete, the research suggests that early mobilization and physical therapy is safe, feasible, and appears beneficial. Findings illustrate potential effects and associations at a physiologic, patient performance, functional, medical outcomes, and health care services level.

The bottom line is having a patient, who for at least a part of the day, can be awake from drug affect, and interact with the environment in a purposeful way is the key foundation to the idea. – John P. Kress, MD

Associations and effects of early mobility programs and/or physical therapist treatment include:

Increased

• Muscle strength
• Respiratory muscle strength
• Hospital functional status
• Functional independence at hospital discharge

Decreased

• Duration mechanical ventilation
• Time to accomplishment of functional milestones
• Airway, pulmonary, and vascular complications,/li>
• ICU Length of Stay
• Overall Hospital Length of Stay
• Costs

What are WE (physical therapists) doing?

Does clinical practice reflect this strong premise suggesting safety, feasibility, and rationale for physical therapists in the ICU? A survey of physical therapists belonging to the acute care section of the American Physical Therapy Association from 2007 suggests physical therapists are more likely to be routinely involved in the ICU with neurologic and trauma related diagnoses as oppose to medical diagnoses. Follow up survey data from 2012 suggests a lower likelihood of mobility as perceived complexity (either medically or logistically) increases.

Now, given the limitations of survey data, firm conclusions on WHY are not possible. But, it appears that as medical complexity increases, the less likely physical therapists are to be involved. The more “medical” the diagnoses, the less likely physical therapists are to be involved. Is this secondary to perceived risk? Lack of perceived benefit? Lack of knowledge in long term outcomes, safety, and feasibility? The ICU equipment? Staffing?

What is the basis of physical therapist decision making regarding patients in the intensive care unit? Are therapists making treatment decisions based on the presence of machines, the logistics, and the fears of worst case outcomes? In proper risk analysis, it is imperative to also assess the risk of not intervening. The long term sequelae of critical illness illustrate the potential risks of a critical illness and ICU course left to “natural history.”

Road Blocks & Speed Bumps

Regardless of the evidence, rationale, safety, and feasibility barriers do exist. These barriers likely exist within and between individual clinicians, specific professions, various departments, different units, and the entirety of each specific hospital. But, barriers also involve the interactions of these individuals and professions at all levels of the hospital. The staffing, patient prioritization, training, knowledge, and historic practice patterns are all important variables requiring considerations. Many factors and individuals result in the overall, but dynamic culture of a unit and/or hospital. In order to facilitate change, an eventual transformation of ICU culture is required.

What do PATIENTS think?

I was never told by anyone what to expect – ICU Survivor

A current randomized control trial entitled Do it Now (Diagnosis and Treatment of Neuromuscular Weakness) is investigating early, intensive physical therapy (7 days a week, 30-60 minutes) and standard physical therapy (3 days a week, 15-20 minutes) in patients requiring mechanical ventilation for greater than 4 days. Part of the study is a survey investigating patient and proxy perceptions of physical therapy. To date no robust investigations of patient, family, and proxy perceptions of early, intensive physical therapy exist. The literature on long term outcomes in conjunction with individual patient stories illustrate the shattering trauma of the ICU:

It’s been two years and I’m still trying to sort out what was real and what wasn’t. I still think about it several times a week and continue to ask questions of my family. I have a compelling need to know what happened to me… – ICU Survivor

Interestingly, regardless of which arm of the above study, patient’s  and proxy’s reported physical therapy as highly necessary and beneficial. Although difficult and requiring significant exertion, both patient groups were satisfied with the experience. Neither group would have requested less therapy sessions. And, in fact, both groups requested slightly more. Maybe engagement in a therapeutic process can decrease some of the trauma of the ICU experience? In a brief video, Dale Needham, MD of Johns Hopkins routinely observes that patients agree:

Patient’s overwhelming tell us is that they like the early physical medicine and rehabilitation, they like being awake. They certainly like getting out of bed and moving. It shows them that there is hope, it shows them there is a life beyond the intensive care unit. And, a life for them to get back to. It gives them goals for improvement, It shows them that they can get better.

Nancy Andrews comments from a patient’s perspective:

I can share advice based on my experience. Reach out to people. Talk about what you remember. Draw, play games, listen to music, dance, DO PHYSICAL THERAPY, Reconstruct what happened and sort it out. Talk to your doctor. Ask for help.

Summary

1. Immobility is PATHOLOGY
2. Critical Illness  is a neuromuscular, cognitive, psychological INSULT
3. Long Term Functional Outcomes are POOR
4. Mechanisms of physical therapy and mobility are likely multi-factorial
5. Physical Therapist practice in the ICU is evolving, but varied
6. Patients & Family’s understand benefit of physical therapy
7. Patient’s & Family’s desire physical therapy

Dale Needham, MD summarizes the issue

We must stop making excuses about why a patient can’t do rehabilitation today—he has a CT scan or she’s getting dialysis. We need to highly prioritize rehabilitation, which we now see as just as—if not more—important than many other tests and treatments we offer our patients in intensive care.

Change is possible. The rationale is present, it is time for action.