Physiotherapy in the ICU

Question 24 from the second paper of 2013 waned to discuss the role of physiotherapists in intensive care, whereas Question 16 from the first paper of 2006 asked specifically what were the risks and benefits of physiotherapy in the ICU. This recalls the chest physiotherapy related  Question 12 from the second paper of 2001, where the college asked the candidates to not only recall some details as to the role of chest physiotherapy in the ICU, but to list the manoeuvres and provide  the rationale for them. In view of that fact that the manoeuvres are well covered in the Chest Physiotherapy chapter, they will not be re-examined here. The best resource for answering such questions would have to be the Oh's Chapter by Moffat and Jones (Physiotherapy in intensive care, p. 38). If for whatever reason one requires a non-Ohs source, Kathy Stiller's review article from CHEST (2000) is the next most useful piece of reading. The most important society statement to become familiar with is the ERS/ESICM Guidelines Statement from 2008.

The best way to approach this topic is by way of the "critically evaluate" answer format.

Physiotherapy as an "introduction" statement

This would have to be a brief fluffy motherhood statement. On offer is the college's own model answer introduction from Question 24:

Physiotherapists are part of the multidisciplinary team providing care to patients in the ICU.

Note how the first line of the model answer includes both the word care  and the word multidisciplinary, both of which are important keywords for the examiner's intracranial SEO. Appropriate triggers are important. Marks are earned in this way.

Rationale for the use of physiotherapy in intensive care

• Functional performance of patients who recover from ICU stay is poor. In one representative longitudinal study, at one year after their ICU stay 69% of survivors were restricted in their ADLs and only 50% had resumed work. (van der Schaaf et al, 2009)
• This is thought to be due to muscular deconditioning, which in turn leads to increased risk of failed ventilator weaning, and prolonged intubation
• Worsened respiratory function due to poor secretion clearance contributes to morbidity and mortality
• Immobility contributes to muscle wasting and joint contractures
• Loss of tonic stimulus leads to hydorxyapatite resorption and bone density loss
• Ergo, therapies aimed at increasing mobility and muscle strength in critical illness should lead to improved functional outcomes and improved mortality/morbidity by addressing these problems.

Techniques and care involvement of ICU physiotherapists

Goals of routine ICU physiotherapy

• Optimisation of cardiopulmonary function
• Assistance in the weaning process utilising ventilatory support and oxygen therapy
• Instigation of an early rehabilitation/mobilisation program to assist in preventing the consequences of enforced immobility
• Advise on positioning to protect joints and to mini-mise potential muscle, soft tissue shortening and nerve damage
• Optimisation of body position to effect muscle tone in the brain-injured patient
• Optimisation of voluntary movement to promote functional independence and improve exercise tolerance
• Management of presenting musculoskeletal pathology
• Advise and education of family and carers
• Liaison with medical and nursing staff on the continuation and monitoring of ongoing physiotherapy-devised care plans.

A more structured list-like answer would resemble the following:

• Respiratory optimisation
  • manual hyperinflation, suction, inspiratory muscle training, positioning, percussion/vibration
• Musculoskeletal optimisation
  • Mobilisation, joint-protective positioning, tone-improving positioning
• Orthopedic
  • Management of immobilisation devices, application and removal of plaster casts, fitting of collars, braces and slings
• Rehabilitation
  • Exercise and education to improve function following a period of critical illness

Specific techniques used in ICU physiotherapy

Specific techniques are well discussed in the excellent recent article by Sommers et al (2015). I paraphrase their Table 2 in the following list:

Passive techniques:

• Passive joint exercises
• Stretching
• Passive cycling
• EMS (electrical muscle stimulation)
• CPM (continuous passive motion) - devices which continuously move a joint through a preprogrammed range of motion
• Splinting

Active techniques:

• Exercise therapy
• ADL (activity of daily living) training
• Out of bed mobilisation
• Cycling

Potential risks to critically ill patients from routine physiotherapy

• Airway trauma from suctioning
• Deterioration in gas exchange
• Barotrauma
• Paradoxically, chest physiotherapy can actually increase the duration of ventilation (Maie et al, 2007)
• Haemodynamic instability
• Increased cardiac output requirements
• Rise in ICP
• Increased patient pain, stress and anxiety
• Risk of falls
• Pressure areas from splints
• Wound dehiscence (eg. of laparotomy wounds)

Society recommendations for the use of physiotherapy in ICU

The ERS/ESICM Guidelines Statement from 2008 makes the following recommendations. Most of them were Level C, because at this stage there were few clinical trials available. Subsequent trials have actually retrospectively supported many of these recommendations.

• Chest physiotherapy: huff, cough, manual bag inflation - all supported by a level B recommendation.
• Oropharyngeal or nasophrangeal suctioning is also recommended (but only on the basis of expert opinion) - but neither suctioning nor instillation of normal saline should be performed routinely.
• Active or passive mobilization and muscle training should be instituted early (C)
• Physiotherapists can be safely left in charge of ventilator weaning and spontaneous breathign trials (level A recommendation)

Evidence for the advantages of routine physiotherapy in the ICU

Mind you there is a massive amount of literature out there. A meta-analysis by Kaymabu et al (2013) identified 10 RCTs. In brief, physiotherapy was found to confer "significant benefit in improving quality of life, physical function, peripheral and respiratory muscle strength, increasing ventilator-free days, and decreasing hospital and ICU stay".  There was no benefit in mortality. A good representative trial is by Burtin et al (2009) - single centre RCT, 90 patients got on to an exercise cycle ergometer as soon as their condition permitted. At intensive care unit discharge, quadriceps force and functional status were not different between groups, but at hospital discharge the 6-minute walking distance, isometric quadriceps force, and the subjective feeling of functional well-being were significantly higher in the treatment group.

Some of the mor recent trials which were not included in this review. Weirdly, these more recent trials are all negative studies.

ACT-ICU trial, Brunnel et al (2014) - 87 patients

• Randomised to either usual care, early once-daily physical therapy, or early once-daily physical therapy plus a novel, progressive, twice-daily cognitive therapy protocol.
• At 3-months, the investigators assessed cognitive, functional and health-related QOL outcomes.
• These did not differ among the groups.
• The authors consoled themselves with the finding that early cognitive and physical  rehabilitation is at least feasible.

Goll et al (2015) - 50 ICU patients subjected to electro-torture to investigate the effects of daily EMS-therapy on muscular strength.

• EMS for 20 minutes 7 days/week to 8 bilateral muscle groups
• No benefit from this was found.

Kayambu et al (2015) - 50 patients with sepsis, randomised to either early physical rehab or routine care.

• Self-reported function was much better at 6 months, but objective measures of function were no different.

EPICC trial, Thomas et al (2015) - still in recruitment phase; 308 patients to be randomised to receive one of two different intensities of physiotherapy.

• The hypothesis is that "physiotherapy aimed at early and intensive patient mobilisation" will improve "improve physical outcomes and the mental health and functional well-being of survivors of critical illness"
• The primary outcome measure is physical health at 6 months, as measured by the SF-36 Physical Component Summary.