Figuring out who should get physical therapy can be tricky
by Joyce Frieden
News Editor, MedPage Today May 24, 2017
WASHINGTON — Striving for early mobilization of intensive care unit (ICU) patients is generally safe, but it is difficult to tell which patients will benefit from it, Marc Moss, MD, of the University of Colorado in Denver, said at American Thoracic Society meeting.
“I think we can [provide mobilization] safely and I don’t think it’s a risk,” he said. “However, with limited resources [we have to make sure there’s a benefit to them].”
Moss showed data from his own institution, which found that the total cost of providing physical therapy (PT) to acute respiratory failure patients was $66,000 per year. Multiplied by many hospitals, “That’s hundreds of millions we’re spending on providing physical therapy to these patients. So how do we allocate resources to the patients who will truly benefit? It’s not a risk/benefit [assessment], it’s more of a cost/benefit [issue].”
The five largest trials looking at the benefits of mobilizing ICU patients have been mixed, Moss noted: two showed positive effects from early mobilization and exercise, while three showed negative effects. “We might want to know, which of these is correct?”
The answer is that “there’s not one that’s correct; they all give us information,” he said. “We want to learn from these studies and design better trials.”
The issue with these studies is that they each look at a different aspect of what PT does for these patients, Moss continued. “Some showed it was beneficial to achieve independent functional status at the time of hospital discharge; that’s an important outcome variable. Some showed we were able to do PT and move [ICU patients] around more — that’s a somewhat important outcome, and others looked at longer-term outcomes.”
There are a lot of issues to consider in terms of PT for these patients: “When should we start it? How long should we do it for and at what intensity? Who should deliver the therapy?” said Moss. “I think we’re in our infancy in this area; we’ve learned a lot but there’s more that we can learn.”
Another consideration is whether there are different phenotypes of ICU-acquired weakness and if so, whether these patients might respond differently to early mobilization and PT. For example, “Studies have shown that people lose muscle mass in the ICU due to inflammation and inactivity, and that’s pretty pervasive, but a subset [of patients] develop myopathy and a subset develop neuropathy, and most that do that will develop both,” he said.
The bottom line, Moss concluded, is that “it’s not practical to treat all ICU patients [with PT] … It’s likely to benefit certain patients but not all, and we need to determine how to benefit those patients and implement a personalized treatment strategy.”
Will Schweickert, MD, of the University of Pennsylvania in Philadelphia, presented a stronger case for early physical activity. “Only one out of every three to five previously independent people with acute respiratory failure lasting 48 hours or more will be able to walk out of the hospital independently,” he said.
Patients on mechanical ventilation are of particular concern, he noted. About 25%-50% of patients on mechanical ventilation develop weakness acquired as a result of being in the ICU; the weakness prolongs ventilation time and length of stay and is independently associated with short-term mortality. In addition, 50%-75% of ventilation patients develop delirium.
And overall, ICU patients get very little activity or socialization. Schweickert cited a study that found patients in the ICU from less than 72 hours up to 7 days were in bed 100% of the time, inactive 92% of the time, and — “pathetically” — alone 36% of the time.
Does exercise help these patients? Studies on the subject are tricky, but five out of seven important trials of early mobilization showed improved patient outcomes, particularly in physical function, he said. However, narrowing that down to trials featuring interventions that begin within 5 days of the illness leaves three trials, all of which found improved outcomes. One of those studies, performed by Schweickert and his colleagues, found that the percentage of patients walking independently at hospital discharge doubled from 25% to 50% with early mobilization.
And there’s another benefit: improved staff morale. Once your staff sees these very sick patients walking, “this is the stuff that changes a unit,” Schweickert said. “Make a difference; get them moving early.”
• Primary Source
American Thoracic Society