Does Intensive Physical Rehabilitation Therapy Decrease Recovery Time for Critically Ill Patients?

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A multicentre, parallel-group, randomised controlled trial has been recently conducted to
determine whether intensive physical rehabilitation therapy training decreases physical and psychological recovery for those who are critically ill, compared to standard physical rehabilitation therapy.

It is widely recognised that both physical and psychological recovery after a period of critical illness is slow and sometimes incomplete. In fact, it has been reported that these patients have physical and psychological problems and a lower quality of life for up to five years after they were diagnosed.

Problems usually arise when muscle wasting begins usually around the first week of critical illness. Therefore if the period of immobility is limited and movement and exercise is promoted, muscle weakness should be prevented which could enhance a patient’s recovery.

Mobilsation has developed due to the need to avoid over sedation, the value of delirium and the importance of spontaneous breathing trials. A trial conducted by Schweickert concluded that early physical and occupational therapy in mechanically ventilated patients in the medical intensive care unit (ICU) saw an increase in better functional outcomes at hospital discharge, a reduced duration of delirium and an increase in the amount of ventilator-free days. Another multicentre trial in the surgical ICU discovered that early, goal-directed mobilisation decreased their patients’ stay and improved functional mobility.

This trial however, was conducted under the hypothesis that the patients’ physical health would improve once they have received intensive physical rehabilitation in ICU in comparison with those who only received the standardised training.

To test this hypothesis, a randomised controlled trial was conducted in order to compare the impact of the two different intensities of early rehabilitation therapy, on the recovery of physical health-related quality of life at six months.

The test was conducted by using a randomised, parallel group, allocation-concealed, assessor-blinded, controlled trial in mixed medical-surgical ICUs of four hospitals in the UK. The trial had ethical approval from Newcastle and North Tyneside 2 Research Ethics Committee (11/NE/0206) and was registered (ISRCTN: 20436833).

Only patients that were 18+ years old and had also received at least 48 hours of invasive or non-invasive ventilation were eligible for inclusion in the trial. A total of 308 patients were recruited over a 34 month time frame.

Functional training and individually tailored exercise programmes were provided to all patients, and all therapy had to be provided by experienced critical care physiotherapists. All participants were randomised in a 1:1 ratio, which was stratified by admitting ICU, admission type and level of independence. The intervention group - consisting of 150 patients - had to do 90 minutes of physical rehabilitation per day, whilst the control group - consisting of 158 patients - only had to do 30 minutes through Monday to Friday. Sessions in both groups had to be stopped immediately if the patient requested.  The primary outcome was the Physical Component Summary (PCS) measure of SF-36 at 6 months.

The results however did not match the hypothesis. The intervention group received on average of 161 minutes of physical rehabilitation on ICU, whilst the control group only received 81 minutes.

After six months, in the intervention group, 11 participants had withdrawn, 34 did not follow-up with their data and 43 had died; and in the control group, 5 had withdrawn, 43 did not follow up with their data and 56 had died. This meant that there were 62 participants left in the intervention group and 54 participants in the control group, and their results were the only contributions to the primary outcome data.

The final results concluded that there was virtually no difference in the primary outcomes at the six month mark. The mean (SD) PCS were as follows: 37 (11.3) in the control group and 37 (21.2) in the intervention group. Therefore, we can be certain that ICU based physical rehabilitation does not improve a patient’s physical health or muscle strength after 6 months  when compared to the standard physical rehabilitation critically ill patients normally receive.