Passive motion of the lower extremities in sedated and ventilated patients in the ICU - a systematic review of early effects and replicability of Interventions

Effectiveness of passive mobilization on the deleterious effects of immobilization in patients with musculoskeletal problems: a systematic review

INTRODUCTION

Joint immobilization may be necessary in some situations, such as in cases of fractures and osteomyoarticular injuries. However, it is known that there are several harmful effects of immobilization, which can cause muscle weakness, loss of motor function, reduced range of motion and increased local pain, and it is important to understand the possible forms of treatment to alleviate the effects of immobilization, focusing on passive mobilization.

OBJECTIVE

To address articles that evaluate the effects of passive mobilization on immobilized patients.

METHODOLOGY

The search was carried out in national and international electronic databases (PubMed, Pedro, Web of Science, Scopus, Embase, Lilacs and Cochrane), in addition to gray literature (Google Scholar, Open Gray and Livivo), using the following descriptors: PASSIVE MOBILIZATION and IMMOBILIZATION, being carried out blindly, by two main researchers, concluding the selection with 6 articles on the subject.

RESULTS

The studies indicate that passive mobilization was able to reverse the negative aspects of immobilization in relation to the recovery of strength, range of movement, local pain and motor function, as its action provides tissue sliding, increasing circulation and the repair process tissue.

CONCLUSION

Although the effects are smaller compared to active exercises, it can be considered that passive mobilization can mitigate the harmful effects of immobilization.

Effects of rapid chest compression technique on intracranial and cerebral perfusion pressures in acute neurocritical patients: a randomized controlled trial

BACKGROUND

Some studies refer to the increase in intracranial pressure (ICP) with chest physiotherapy techniques but without any randomized controlled trials that evaluate the safety of the manual rapid chest compression technique in patients with severe acute brain injuries on invasive mechanical ventilation. Our research question examines whether intracranial and cerebral perfusion pressures significantly change during rapid chest compression technique.

METHODS

A prospective, randomized, single-blinded controlled trial of acute neurocritical patients under mechanical ventilation was performed. The intervention group was subjected to rapid chest compression, and the control group received mechanical passive inferior limbs mobilization. The outcomes were intracranial pressure, cerebral perfusion pressure, blood partial pressure of oxygen and carbon dioxide, and inspiratory and expiratory peak flows.

RESULTS

Between May 2021 and December 2023, 50 patients (aged 56.3 years), 66% females, were randomized into two groups (25 controls and 25 interventions). The ICP and cerebral perfusion pressure (CPP) did not significantly differ between the groups at any of the studied times. Intragroup analysis revealed significant decreases in the ICP and CPP in the intervention group, with posterior recovery in both groups. The CPP significantly decreased in the control group but did not reach the preintervention values at the last measurement time. PaCO2 was significantly lower in the intervention group than in the control group at the end of the study.

CONCLUSION

The rapid chest compression technique did not increase the ICP during its application or even 30 min after it. The ICP showed a slight significant decrease during the application of the rapid chest compression technique but reached the previous values in the posterior 30 min. CPP had a similar behavior but did not completely recover in both groups.

TRIAL REGISTRATION

NCT03609866. Registered on 08/01/2018.

Effects of in-bed cycling in critically ill adults: A systematic review and meta-analysis of randomised clinical trials

BACKGROUND

Impairments in intensive care unit (ICU) survivors can last up to 5 years post-discharge. Finding effective treatments to palliate and prevent them is essential, and in-bed cycling is a way to palliate the effects of prolonged immobilisation.

OBJECTIVE

To evaluate the effects of in-bed cycling in critically ill adults regarding recovery status, mortality, physical performance and quality of life.

METHODS

We followed PRISMA 2020 guidelines. The search was conducted in Cinahl, Medline, Scopus and Web of Science from their inception to October 2024. We included randomised clinical trials with critically ill adults who performed in-bed cycling alone or with another treatment while in ICU, compared to no intervention, placebo, rehabilitation or standard care, assessing recovery status, mortality, physical performance or quality of life. Methodological quality and risk of bias were evaluated. A meta-analysis was performed.

RESULTS

Thirty-two studies were included in the review, and 22 studies in the meta-analysis. A total of 3,052 participants (≥18 years old) admitted to different types of ICUs were included. Results showed significant differences regarding ICU length of stay (n = 1,564; MD -0.93; 95 % CI -1.64 to -0.21; P = 0.01) and hospital length of stay (n = 1,189; MD -1.78; 95 % CI -3.16 to -0.41; P = 0.01), mechanical ventilation duration (n = 1,024; MD -0.51; 95 % CI -0.92 to -0.11; P = 0.01) and functional status (n = 400; MD 44.88; 95 % CI 3.11-86.65; P = 0.04) favouring in-bed cycling plus rehabilitation compared to rehabilitation. However, no significant differences were found regarding mortality, muscle strength, ICU-acquired weakness or quality of life. Different programme duration did not significantly affect hospital length of stay.

CONCLUSION

In-bed cycling plus rehabilitation significantly reduced ICU and hospital length of stay, mechanical ventilation duration and improved functional status compared to rehabilitation. Further research is needed to analyse long-term effects and standardise interventions.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022309311; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022309311.

The three stages of polytrauma rehabilitation- a recommendation and a systematic literature review on behalf of SICOT

PURPOSE

Polytrauma presents a devastating event with great impact on the patient's life. While we are taking great care of improving our treatment algorithms, the rehabilitation often takes place outside of our direct field of vision. Yet, adequate rehabilitation is crucial for the patients to regain their former lives. The aim of this study, on the behalf of SICOT Trauma & Rehabilitation Research Group, was to identify rehabilitation strategies and standards in existing scientific literature.

METHODS

A systematic literature search of MEDLINE and Embase from 2000 to 2023 was conducted. Inclusion criteria was the description of polytrauma rehabilitation strategies in the acute, post-acute or long-term stage. Reported treatment aims, conducted therapies and challenges were extracted and stratified to either of the stages.

RESULTS

A total of 5212 studies were identified and 6 reviews and one original study were included according to our criteria. Overall, no article of higher evidence on how to perform polytrauma rehabilitation could be identified. From the available literature, disciplines involved in the rehabilitation could be described such as major challenges along the rehabilitation process.

CONCLUSION

This study highlights the need for standardized polytrauma rehabilitation algorithms. Whereas we could identify important information about each rehabilitation stage, we did not encounter specific evidence for prioritization of different therapies or algorithms of treatment. Polytrauma rehabilitation needs to shift from eminence to evidence.

Early Rehabilitation in Acute Respiratory Distress Syndrome

Providing early rehabilitation during critical illness is considered best practice; however, the respiratory compromise suffered by patients with ARDS often limits their capacity to participate in active exercise. This article outlines the current evidence regarding early rehabilitation in the ICU with a specific focus on the considerations for this cohort. It provides some practical recommendations to assist clinicians in the identification of appropriate early rehabilitation techniques, taking into account disease severity and medical management strategies. It outlines methods to ensure the safe implementation of early rehabilitation with the aim of improving the outcomes of ARDS survivors.

Guideline on positioning and early mobilisation in the critically ill by an expert panel

A scientific panel was created consisting of 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology delegated from scientific societies together with a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II. The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The panel formulated PICO questions (addressing the population, intervention, comparison or control group as well as the resulting outcomes), conducted a systematic literature review with abstract screening and full-text analysis and created summary tables. This was followed by grading the evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and a risk of bias assessment. The recommendations were finalized according to GRADE and voted using an online Delphi process followed by a final hybrid consensus conference. The German long version of the guideline was approved by the professional associations. For this English version an update of the systematic review was conducted until April 2024 and recommendation adapted based on new evidence in systematic reviews and randomized controlled trials. In total, 46 recommendations were developed and research gaps addressed.

From bedside to recovery: exercise therapy for prevention of post-intensive care syndrome

BACKGROUND

As advancements in critical care medicine continue to improve Intensive Care Unit (ICU) survival rates, clinical and research attention is urgently shifting toward improving the quality of survival. Post-Intensive Care Syndrome (PICS) is a complex constellation of physical, cognitive, and mental dysfunctions that severely impact patients' lives after hospital discharge. This review provides a comprehensive and multi-dimensional summary of the current evidence and practice of exercise therapy (ET) during and after an ICU admission to prevent and manage the various domains of PICS. The review aims to elucidate the evidence of the mechanisms and effects of ET in ICU rehabilitation and highlight that suboptimal clinical and functional outcomes of ICU patients is a growing public health concern that needs to be urgently addressed.

MAIN BODY

This review commences with a brief overview of the current relationship between PICS and ET, describing the latest research on this topic. It subsequently summarises the use of ET in ICU, hospital wards, and post-hospital discharge, illuminating the problematic transition between these settings. The following chapters focus on the effects of ET on physical, cognitive, and mental function, detailing the multi-faceted biological and pathophysiological mechanisms of dysfunctions and the benefits of ET in all three domains. This is followed by a chapter focusing on co-interventions and how to maximise and enhance the effect of ET, outlining practical strategies for how to optimise the effectiveness of ET. The review next describes several emerging technologies that have been introduced/suggested to augment and support the provision of ET during and after ICU admission. Lastly, the review discusses future research directions.

CONCLUSION

PICS is a growing global healthcare concern. This review aims to guide clinicians, researchers, policymakers, and healthcare providers in utilising ET as a therapeutic and preventive measure for patients during and after an ICU admission to address this problem. An improved understanding of the effectiveness of ET and the clinical and research gaps that needs to be urgently addressed will greatly assist clinicians in their efforts to rehabilitate ICU survivors, improving patients' quality of survival and helping them return to their normal lives after hospital discharge.

Early mobilisation within 72 hours after admission of critically ill patients in the intensive care unit: A systematic review with network meta-analysis

INTRODUCTION

Early mobilisation within 72 hours of intensive care unit admission counteracts complications caused by critical illness. The effect of different interventions on intensive care unit length of stay and other outcomes is unclear. We aimed to investigate the effectiveness of various early mobilisation interventions within 72 hours of admission to the intensive care unit on length of stay and other outcomes.

METHODS

A systematic review and (network) meta-analysis examining the effect of early mobilisation on length of stay in the intensive care unit and other outcomes, conducting searches in four databases. Randomised controlled trials were included from inception to 10/08/2022. Early mobilisation was defined as interventions that initiates and/or supports passive/active range-of-motion exercises within 72 hours of admission. In multi-arm studies, interventions used in other studies were declared as early intervention and were included in subgroup meta-analysis. Risk-of-bias was assessed using RoB2.

RESULTS

Of 29,680 studies screened, 18 studies with 1923 patients (three high, eleven some, four low risk-of-bias) and seven discriminable interventions of early mobilisation met inclusion criteria. Early mobilisation alone (WMD 0.78 days, 95 %CI [-1.38;-0.18], 11 studies, n = 1124) and early mobilisation with early nutrition (WMD -1.19 days, 95 %CI [-2.34;-0.03], 1 study, n = 100) were able to significantly shorten length of stay. Early mobilisation alone could also substantially shorten hospital length of stay (WMD -1.05 days, 95 %CI [-1.74;-0.36], 8 studies, n = 977). This effect in hospital length of stay was furthermore seen in the early intervention group compared with standard care (WMD -1.71 days, 95 %CI [-2.99;-0.43], 14 studies, n = 1587). Also, functionality and quality of life could significantly be improved by an early start of mobilisation.

CONCLUSION

In the network meta-analysis, early mobilisation alone and early mobilisation with early nutrition demonstrated a significant effect on intensive care length of stay. Early mobilisation could also reduce hospital length of stay and positively influence functionality and quality of life.

IMPLICATION FOR CLINICAL PRACTICE

Early mobilisation and early mobilisation with early nutrition seemed to be beneficial compared to other interventions like cycling on intensive care length of stay.

The effects of early mobilization in mechanically ventilated adult ICU patients: systematic review and meta-analysis

Background

The effects of early mobilization (EM) on intensive care unit (ICU) patients remain unclear. A meta-analysis of randomized controlled trials was performed to evaluate its effect in mechanically ventilated adult ICU patients.

Methods

We searched randomized controlled trials (RCTs) published in Medline, Embase, and CENTRAL databases (from inception to November 2022). According to the difference in timing and type, the intervention group was defined as a systematic EM group, and comparator groups were divided into the late mobilization group and the standard EM group. The primary outcome was mortality. The secondary outcomes were ICU length of stay, duration of mechanical ventilation (MV), and adverse events. EM had no impact on 180-day mortality and hospital mortality between intervention groups and comparator groups (RR 1.09, 95% CI 0.89-1.33, p = 0.39). Systemic EM reduced the ICU length of stay (LOS) (MD -2.18, 95% CI -4.22--0.13, p = 0.04) and the duration of MV (MD -2.27, 95% CI -3.99--0.56, p = 0.009), but it may increase the incidence of adverse events in patients compared with the standard EM group (RR 1.99, 95% CI 1.25-3.16, p = 0.004).

Conclusion

Systematic EM has no significant effect on short- or long-term mortality in mechanically ventilated adult ICU patients, but systematic EM could reduce the ICU LOS and duration of MV.

Facilitators & barriers and practices of early mobilization in critically ill burn patients: A survey

BACKGROUND

Early mobilization (EM) of intensive care (IC) patients is important but complex with facilitators and barriers. Compared to general IC patients, burn IC patients are more hyper-metabolic. They have extensive wounds, lengthy wound dressing changes, and repeated surgeries that may affect possibilities of EM. This study aimed to identify facilitators and barriers of EM in burn IC patients among all disciplines involved. Additionally, we assessed EM practices, i.e. when are which patients considered suitable for EM.

METHODS

A survey was sent to 139 professionals involved in EM of burn IC patients (discipline groups: Intensivists, medical doctors, registered nurses, therapists).

RESULTS

Response rate was 57 %. The majority found EM very important, yet different definitions were chosen. Perceived barriers mainly concerned patient-level factors, most frequently hemodynamic instability and excessive sedation followed by skin graft surgery, fatigue, and pain management. Most frequent barriers at the provider-level were limited staffing, safety concerns, and conflicting perceptions about the suitability of EM. At the institutional-level, we found no high barriers. Interdisciplinary variation on perceived barriers, when to initiate it, and permitted maximal activity were ascertained.

CONCLUSION

Skin grafts and pain management were barriers of EM specific for burn care. Opinions on frequency, dosage and duration of EM varied widely. Improving interdisciplinary communication is key.