Matthew Limb looks at the rehabilitation prospects for patients leaving intensive care.
Survival course Matthew Limb looks at the rehabilitation prospects for patients leaving intensive care Medical advances mean patients in intensive care units now have a better than ever chance of survival, but many who do survive then go on to struggle once they have left the ICU. The effects of intensive care, such as those resulting from prolonged periods of inactivity and receiving drugs such as sedatives and corticosteroids, can take a considerable toll. And research has shown ‘severe and prolonged weakness’ is present in one in four patients who are mechanically ventilated for more than seven days. Prolonged ventilation in critical care has been linked with impaired health-related quality of life up to three years after discharge. David McWilliams, a senior specialist physiotherapist working in critical care at Manchester Royal Infirmary, says: ‘We know even a day in ICU can have a profound effect, physically and psychologically.’ Such deterioration may include significant loss of functioning, muscle wasting, problems with stamina and motivation, and increased levels of anxiety and depression. DOWNWARD SPIRAL While there is growing evidence for the role of exercise rehabilitation beginning in the ICU and proceeding beyond ICU discharge, so far there have been few clinical trials by physiotherapists to establish the effectiveness of such treatments. Mr McWilliams, who is trying to plug that gap, has been concerned for some time at the lack of help available to ICU patients once they have left hospital. He says: ‘If they start to exercise or climb a flight of stairs at home and get breathless, they might stop because they worry they’re getting unwell again. Suddenly they’re in this cycle of decreased fitness and they become more anxious.’ At Manchester, post-ICU patients are invited to return for rehabilitation as outpatients within about two weeks of discharge. After an initial assessment, they follow a six-week programme of exercise, plus classes on managing breathlessness and anxiety, relaxation and smoking cessation. The exercise circuit consists of 10 stations, allowing patients to work at varying levels of intensity. Mr McWilliams says results from a pilot study on about 40 patients have been significant. Not only have there been physical improvements – scores for six-minute and incremental shuttle walk tests went up between 60 and 90 per cent – but big reductions in both depression and anxiety levels. GATHERING THE EVIDENCE Mr McWilliams, who runs the programme with rotational senior II physiotherapists, explains: ‘We see people on the programme really come out of themselves and their quality of life is much improved. The programme fits in quite well as it is just before the period where they come back for ICU follow-up, which is generally about three months.’ A key aim in devising the programme was to make it suitable for all types of patients, no matter what the reason for their stay in intensive care. ‘That was the initial challenge,’ Mr McWilliams says. ‘How do you set up a programme for a group that could include an 18-year-old footballer who’s been in a car crash and an 80-year-old with chronic obstructive pulmonary disease? But we have tailored it to a wide variety of people and they all do seem to get benefits from it.’ The next challenge is to garner more robust evidence to support the case for more rehab services. To this end, a randomised controlled trial is now underway at Manchester and is expected to be completed within 18 months. A 2006 survey found only 30 per cent of ICUs across the UK provided follow-up. The proportion of this patient group receiving any sort of physiotherapy follow-up is less than one in 10. ‘It’s kind of chicken and egg,’ Mr McWilliams says. ‘Until we can finish the research study and prove its effectiveness, the funding [to expand the service] won’t follow.’ Mr McWilliams’s goal is to spread the message about what rehab can do for ICU patients. He gave a talk to the Intensive Care Society’s spring meeting and will speak at this year’s CSP Congress in Manchester. He is also a member of the National Institute of Health and Clinical Excellence group that is developing guidelines on critical illness rehabilitation (due for publication in spring 2009). He hopes that by next year, NICE will recommend some form of physical follow-up after discharge from hospital and will have carried out a cost analysis. ‘I’ll do everything in my power to make sure these programmes are part of that,’ he says. ‘I think in reality we’ll get a combination of a structured self-help rehab manual, but then, for those who need it, more structured programmes, He says his own figures show the current programme costs about £350 per patient. PINPOINTING THE PROBLEMS At Ninewells hospital in Dundee, physiotherapists are taking a slightly different approach. Sarah Matthews, physio team leader in critical care, is carrying out a review to establish what ICU patients need in terms of rehab, with a view to developing services. Acknowledging the growth of research, she explains: ‘We felt there were a lot of different things going on and we wanted to identify exactly where on the patient journey the main problems were, so we could then look at targeting.’ Ms Matthews’ team is currently collecting baseline data in order to build up a complete picture. ‘It’s looking at where exactly the rehab would be most effective, whether we need to do much more early on, whether it needs to be more ward-based or whether it needs to take place once they go home, she says. Her gut feeling is that there is a need for all three, with different emphases, depending on the timing of the intervention. ‘ICU rehab is going to be along the lines of maintaining range of movement, trying to maintain muscle strength and respiratory function, while on the wards it’s probably going to be more functional,’ she explains. ‘At home it’ll probably be more related to exercise capacity and cardiovascular fitness.’ The team will use questionnaires to examine patients’ perceptions of their rehab needs and any issues raised by staff. Ms Matthews expects the project to take a year and hopes to share data with Mr McWilliams and other colleagues in this field, including the Scottish physiotherapy critical care network. WHAT THE PATIENT WANTS At the same time, physios working in critical care at Raigmore hospital, Inverness, have produced an information pack to help guide patients and relatives through the recovery phase. Morag Ross and Suzanne Lindsay, of the surgical physiotherapy team, developed the pack after discussions with patients. Ms Ross says: ‘We knew from reading articles and iCSP [interactiveCSP, the Society’s member networking website] that there was a drive towards more rehab within ICU.’ The pack includes information on relaxation and breathing exercises as well as diet, with the aim of improving physical and psychological wellbeing. It will be audited by means of a patient questionnaire to ensure it continues to meet patients’ needs. ‘The plan then,’ says Ms Ross, ‘is to put together a business case for a critical care rehab post in the unit, trying to implement more patient-centred rehab services for people in critical care and possibly even discharge classes at Raigmore.’ This, and more research, is what is needed to improve post-ICU rehab care. FL International research In 2006, two physiotherapists in Australia published a review of physiotherapy in the intensive care unit.1 It summarised the evidence for the role of physio in the adult ICU in relation to respiratory management, including non-invasive ventilation, exercise, and short- and longer-term rehabilitation. The authors concluded the safety of physio treatment in ICU was established and they highlighted growing evidence for the role of exercise rehabilitation starting in ICU and extending to post discharge. But they noted there were few randomised controlled trials establishing the effectiveness of such treatments and said there was an urgent need for research. The authors, Linda Denehy and Sue Berne, have begun a randomised controlled trial at Melbourne’s Austin hospital involving around 200 patients. They are comparing physiotherapy exercise rehabilitation in ICU survivors to standard care with a 12-month follow-up. The primary outcomes of interest are physical function and health-related quality of life. The intervention group will receive intensive rehab starting in ICU, continuing on to the general ward and then, after discharge home, twice weekly in outpatients for eight weeks. Dr Denehy hopes the results will change future clinical practice for the treatment of ICU patients, and be used to develop national guidelines in Australia. Reference 1 Denehy et al. ‘Physiotherapy in the intensive care unit’, Physical Therapy Reviews (2006), 11: 1 Top tips for setting up a rehab service • involve the medical discharge team at an early stage, including ICU/follow-up consultants • set clear inclusion and exclusion criteria; that is, all patients admitted to ICU or those with a length of stay of more than five days • select validated outcome measures; for example, include six-minute walk test, incremental shuttle walk (SF-36 questionnaire) • consider physical and psychological components; that is, education on anxiety management • the circuit approach to exercise is very effective in improving upper and lower limb strength as well as cardiovascular fitness • don’t be deterred by a lack of evidence – use the evidence base from cardiac and pulmonary rehab services • don’t be afraid to ask for help if you feel isolated Source: David McWilliams, senior specialist physiotherapist – critical care, Manchester Royal Infirmary The patient’s viewpoint Desmond White recalls being ‘at death’s door’ when he was admitted to Manchester Royal Infirmary’s intensive care unit with pneumonia in 2005. He spent several weeks on a ventilator until he was declared well enough to go home, but it was a long hard road to full recovery for the 66-year-old excavator operator. ‘I lost a lot of weight while I was in hospital. I was depressed with my illness and looked a bit of a sight really,’ he says. ‘My confidence was very, very low. I didn’t want to go out, I felt really down.’ Within a few weeks, Mr White was invited back to the hospital for rehabilitation. He started circuit training in the gym and was able to discuss his condition with physiotherapy and nursing staff. He was given a range of helpful advice, including about getting motivated and about breathing. He says that he then began to ‘buck up’, as he puts it, getting physically stronger and putting weight back on. He was later able to carry on with exercises at home. ‘Everybody on this course now feels how I felt. They say how much it helps them and how they feel better for it,’ Mr White adds.
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