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The effects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review

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Abstract

Purpose

Early active mobilisation and rehabilitation in the intensive care unit (ICU) is being used to prevent the long-term functional consequences of critical illness. This review aimed to determine the effect of active mobilisation and rehabilitation in the ICU on mortality, function, mobility, muscle strength, quality of life, days alive and out of hospital to 180 days, ICU and hospital lengths of stay, duration of mechanical ventilation and discharge destination, linking outcomes with the World Health Organization International Classification of Function Framework.

Methods

A PRISMA checklist-guided systematic review and meta-analysis of randomised and controlled clinical trials.

Results

Fourteen studies of varying quality including a total of 1753 patients were reviewed. Active mobilisation and rehabilitation had no impact on short- or long-term mortality (p > 0.05). Meta-analysis showed that active mobilisation and rehabilitation led to greater muscle strength (body function) at ICU discharge as measured using the Medical Research Council Sum Score (mean difference 8.62 points, 95% confidence interval (CI) 1.39–15.86), greater probability of walking without assistance (activity limitation) at hospital discharge (odds ratio 2.13, 95% CI 1.19–3.83), and more days alive and out of hospital to day 180 (participation restriction) (mean difference 9.69, 95% CI 1.7–17.66). There were no consistent effects on function, quality of life, ICU or hospital length of stay, duration of mechanical ventilation or discharge destination.

Conclusion

Active mobilisation and rehabilitation in the ICU has no impact on short- and long-term mortality, but may improve mobility status, muscle strength and days alive and out of hospital to 180 days.

Registration of protocol number

CRD42015029836.

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References

  1. Gosselink R, Bott J, Johnson M, Dean E, Nava S, Norrenberg M, Schonhofer B, van de Leur H, Vincent JL (2008) Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med 34:1188–1199

    Article  CAS  PubMed  Google Scholar 

  2. Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Phadke R, Dew T, Sidhu PS, Velloso C, Seymour J, Agley CC, Selby A, Limb M, Edwards LM, Smith K, Rowlerson A, Rennie MJ, Moxham J, Harridge SD, Hart N, Montgomery HE (2013) Acute skeletal muscle wasting in critical illness. JAMA 310(15):1591–1600. doi:10.1001/jama.2013.278481

    Article  CAS  PubMed  Google Scholar 

  3. Winkelman C (2007) Inactivity and inflammation in the critically ill patient. Crit Care Clin 23(1):21–34. doi:10.1016/j.ccc.2006.11.002

    Article  CAS  PubMed  Google Scholar 

  4. Truong AD, Fan E, Brower RG, Needham DM (2009) Bench-to-bedside review: mobilizing patients in the intensive care unit—from pathophysiology to clinical trials. Crit Care 13(4):216. doi:10.1186/cc7885

    Article  PubMed  PubMed Central  Google Scholar 

  5. Team Study Investigators (2015) Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care 19(1):81. doi:10.1186/s13054-015-0765-4

    Article  Google Scholar 

  6. Iwashyna TJ (2012) Trajectories of recovery and dysfunction after acute illness, with implications for clinical trial design. Am J Respir Crit Care Med 186(4):302–304. doi:10.1164/rccm.201206-1138ED

    Article  PubMed  PubMed Central  Google Scholar 

  7. Herridge MS, Tansey CM, Matte A, Tomlinson G, Diaz-Granados N, Cooper A, Guest CB, Mazer CD, Mehta S, Stewart TE, Kudlow P, Cook D, Slutsky AS, Cheung AM, Canadian Critical Care Trials Group (2011) Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 364(14):1293–1304. doi:10.1056/NEJMoa1011802

    Article  CAS  PubMed  Google Scholar 

  8. Bagshaw SM, Stelfox HT, Johnson JA, McDermid RC, Rolfson DB, Tsuyuki RT, Ibrahim Q, Majumdar SR (2015) Long-term association between frailty and health-related quality of life among survivors of critical illness: a prospective multicenter cohort study. Crit Care Med 43(5):973–982. doi:10.1097/CCM.0000000000000860

    Article  PubMed  Google Scholar 

  9. Puthucheary ZA, Denehy L (2015) Exercise interventions in critical illness survivors: understanding inclusion and stratification criteria. Am J Respir Crit Care Med 191(12):1464–1467. doi:10.1164/rccm.201410-1907LE

    Article  PubMed  Google Scholar 

  10. McNelly AS, Rawal J, Shrikrishna D, Hopkinson NS, Moxham J, Harridge SD, Hart N, Montgomery HE, Puthucheary ZA (2016) An exploratory study of long-term outcome measures in critical illness survivors: construct validity of physical activity, frailty, and health-related quality of life measures. Crit Care Med 44(6):e362–e369. doi:10.1097/CCM.0000000000001645

    Article  PubMed  Google Scholar 

  11. Connolly B, O’Neill B, Salisbury L, Blackwood B, Enhanced Recovery After Critical Illness Programme Group (2016) Physical rehabilitation interventions for adult patients during critical illness: an overview of systematic reviews. Thorax. doi:10.1136/thoraxjnl-2015-208273

    Google Scholar 

  12. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman A, Barr R, McCallister KE, Hall JB, Kress JP (2009) Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised control trial. Lancet 373:1874–1882

    Article  PubMed  Google Scholar 

  13. Needham DM (2008) Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA 300(14):1685–1690. doi:10.1001/jama.300.14.1685

    Article  CAS  PubMed  Google Scholar 

  14. Castro-Avila AC, Seron P, Fan E, Gaete M, Mickan S (2015) Effect of early rehabilitation during intensive care unit stay on functional status: systematic review and meta-analysis. PLoS One 10(7):e0130722. doi:10.1371/journal.pone.0130722

    Article  PubMed  PubMed Central  Google Scholar 

  15. Avert Trial Collaboration Group, Bernhardt J, Langhorne P, Lindley RI, Thrift AG, Ellery F, Collier J, Churilov L, Moodie M, Dewey H, Donnan G (2015) Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet 386(9988):46–55. doi:10.1016/S0140-6736(15)60690-0

    Article  Google Scholar 

  16. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6(7):e1000097. doi:10.1371/journal.pmed.1000097

    Article  PubMed  PubMed Central  Google Scholar 

  17. Higgins JPT, Green S (2011) Cochrane handbook for systematic reviews of interventions version 5.1.0. The Cochrane Collaboration. http://www.handbook.cochrane.org. Accessed Mar 2011

  18. National Insitute for Health Research (2015) PROSPERO International prospective register of systematic review. http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015029836. Accessed Nov 2015

  19. NHMRC Clinical Trials Centre: Australian and New Zealand Clinical Trials Registry: http://www.ctc.usyd.edu.au/prospective-trial-registration/australian-new-zealand-clinical-trials-registry-(anzctr).aspx. Accessed June 2016

  20. US National Institutes of Health ClinicalTrials.gov, a registry and results database of publicly and privately supported clinical studies of human participants conducted around the world: https://clinicaltrials.gov/ https://clinicaltrials.gov/. Accessed June 2016

  21. World Health Organization (2013) International classification of functioning, disability and health. ICF, Geneva

    Google Scholar 

  22. Covidence systematic review software: a collaboration between Cochrane and the team of systematic reviewers, designers and software developers that developed the ReGroup and EROS software prototypes with support from The Alfred Hospital, Monash University, National ICT Australia, University College London and Instituto de Effectividad Clinica y Sanitaria (2015)

  23. Hodgson CL, Bailey M, Bellomo R, Berney S, Buhr H, Denehy L, Gabbe B, Harrold M, Higgins A, Iwashyna TJ, Papworth R, Parke R, Patman S, Presneill J, Saxena M, Skinner E, Tipping C, Young P, Webb S, Trial of Early Activity and Mobilization Study Investigators (2016) A binational multicenter pilot feasibility randomized controlled trial of early goal-directed mobilization in ICU. Crit Care Med. doi:10.1097/CCM.0000000000001643

    Google Scholar 

  24. Altman DG, Bland JM (1996) Detecting skewness from summary information. BMJ 313(7066):1200

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Kayambu G, Boots R, Paratz J (2015) Early physical rehabilitation in intensive care patients with sepsis syndromes: a pilot randomised controlled trial. Intensive Care Med 41(5):865–874. doi:10.1007/s00134-015-3763-8

    Article  PubMed  Google Scholar 

  26. Brummel NE, Girard TD, Ely EW, Pandharipande PP, Morandi A, Hughes CG, Graves AJ, Shintani A, Murphy E, Work B, Pun BT, Boehm L, Gill TM, Dittus RS, Jackson JC (2014) Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the activity and cognitive therapy in ICU (ACT-ICU) trial. Intensive Care Med 40(3):370–379. doi:10.1007/s00134-013-3136-0

    Article  CAS  PubMed  Google Scholar 

  27. Denehy L, Skinner EH, Edbrooke L, Haines K, Warrillow S, Hawthorne G, Gough K, Hoorn SV, Morris ME, Berney S (2013) Exercise rehabilitation for patients with critical illness: a randomized controlled trial with 12 months of follow-up. Crit Care 17(4):R156. doi:10.1186/cc12835

    Article  PubMed  PubMed Central  Google Scholar 

  28. Dong ZH, Yu BX, Sun YB, Fang W, Li L (2014) Effects of early rehabilitation therapy on patients with mechanical ventilation. World J Emerg Med 5(1):48–52. doi:10.5847/wjem.j.1920-8642.2014.01.008

    Article  PubMed  PubMed Central  Google Scholar 

  29. Hanekom SD, Louw Q, Coetzee A (2012) The way in which a physiotherapy service is structured can improve patient outcome from a surgical intensive care: a controlled clinical trial. Crit Care 16(6):R230. doi:10.1186/cc11894

    Article  PubMed  PubMed Central  Google Scholar 

  30. Moss M, Nordon-Craft A, Malone D, Van Pelt D, Frankel SK, Warner ML, Kriekels W, McNulty M, Fairclough DL, Schenkman M (2016) A randomized trial of an intensive physical therapy program for acute respiratory failure patients. Am J Respir Crit Care Med 193(10):1101–1110. doi:10.1164/rccm.201505-1039OC

    Article  PubMed  Google Scholar 

  31. Yosef-Brauner O, Adi N, Ben Shahar T, Yehezkel E, Carmeli E (2015) Effect of physical therapy on muscle strength, respiratory muscles and functional parameters in patients with intensive care unit-acquired weakness. Clin Respir J 9(1):1–6. doi:10.1111/crj.12091

    Article  PubMed  Google Scholar 

  32. Dantas CM, Silva PF, Siqueira FH, Pinto RM, Matias S, Maciel C, Oliveira MC, Albuquerque CG, Andrade FM, Ramos FF, Franca EE (2012) Influence of early mobilization on respiratory and peripheral muscle strength in critically ill patients. Rev Bras Ter Intensiva 24(2):173–178

    Article  PubMed  Google Scholar 

  33. Dong Z, Yu B, Zhang Q, Pei H, Xing J, Fang W, Sun Y, Song Z (2016) Early rehabilitation therapy is beneficial for patients with prolonged mechanical ventilation after coronary artery bypass surgery. Int Heart J 57(2):241–246. doi:10.1536/ihj.15-316

    Article  PubMed  Google Scholar 

  34. Morris PE, Berry MJ, Files DC, Thompson JC, Hauser J, Flores L, Dhar S, Chmelo E, Lovato J, Case LD, Bakhru RN, Sarwal A, Parry SM, Campbell P, Mote A, Winkelman C, Hite RD, Nicklas B, Chatterjee A, Young MP (2016) Standardized rehabilitation and hospital length of stay among patients with acute respiratory failure: a randomized clinical trial. JAMA 315(24):2694–2702. doi:10.1001/jama.2016.7201

    Article  CAS  PubMed  Google Scholar 

  35. Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, Ross A, Anderson L, Baker S, Sanchez M, Penley L, Howard A, Dixon L, Leach S, Small R, Hite RD, Haponik E (2008) Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 36(8):2238–2243. doi:10.1097/CCM.0b013e318180b90e

    Article  PubMed  Google Scholar 

  36. Schaller SJ, Anstey M, Blobner M, Edrich T, Grabitz SD, Gradwohl-Matis I, Heim M, Houle T, Kurth T, Latronico N, Lee J, Meyer MJ, Peponis T, Talmor D, Velmahos GC, Waak K, Walz JM, Zafonte R, Eikermann M, International Early SOMS-guided Mobilization Research Initiative (2016) Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial. Lancet 388(10052):1377–1388. doi:10.1016/S0140-6736(16)31637-3

    Article  PubMed  Google Scholar 

  37. Wolfe KS, Wendlandt BN, Patel SB, Patel BK, Greenberg JA, Pohlman AS, Hall JB, Kress JP (2013) Long-term survival and health care utilization of mechanically ventilated patients in a randomized controlled trial of early mobilization. Am J Respir Crit Care Med 187:A5235

  38. Tipping CJ, Bailey MJ, Bellomo R, Berney S, Buhr H, Denehy L, Harrold M, Holland A, Higgins AM, Iwashyna TJ, Needham D, Presneill J, Saxena M, Skinner EH, Webb S, Young P, Zanni J, Hodgson CL (2016) The ICU mobility scale has construct and predictive validity and is responsive: a multicenter observational study. Ann Am Thorac Soc 13(6):887–893. doi:10.1513/AnnalsATS.201510-717OC

    Article  PubMed  Google Scholar 

  39. Hodgson CL, Stiller K, Needham DM, Tipping CJ, Harrold M, Baldwin CE, Bradley S, Berney S, Caruana LR, Elliott D, Green M, Haines K, Higgins AM, Kaukonen KM, Leditschke IA, Nickels MR, Paratz J, Patman S, Skinner EH, Young PJ, Zanni JM, Denehy L, Webb SA (2014) Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Crit Care 18(6):658. doi:10.1186/s13054-014-0658-y

    Article  PubMed  PubMed Central  Google Scholar 

  40. Greening NJ, Williams JE, Hussain SF, Harvey-Dunstan TC, Bankart MJ, Chaplin EJ, Vincent EE, Chimera R, Morgan MD, Singh SJ, Steiner MC (2014) An early rehabilitation intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease: randomised controlled trial. BMJ 349:g4315. doi:10.1136/bmj.g4315

    Article  PubMed  PubMed Central  Google Scholar 

  41. Kayambu G, Boots R, Paratz J (2013) Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med 41(6):1543–1554. doi:10.1097/CCM.0b013e31827ca637

    Article  PubMed  Google Scholar 

  42. Blackwood B, Marshall J, Rose L (2015) Progress on core outcome sets for critical care research. Curr Opin Crit Care 21(5):439–444. doi:10.1097/MCC.0000000000000232

    Article  PubMed  Google Scholar 

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Acknowledgements

To the authors who supplied clarification of published data and provided unpublished results: Professor Linda Denehy, Dr. Marc Moss, Geetha Kayambu, Dr. Krysta Wolfe and Dr. Nathan Brummel.

Author information

Authors and Affiliations

  1. Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia

    Claire J. Tipping & Carol L. Hodgson

  2. Department of Physiotherapy, The Alfred Hospital, Melbourne, VIC, Australia

    Claire J. Tipping, Anne Holland & Carol L. Hodgson

  3. Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia

    Travis Nisbet

  4. Curtin University, Perth, WA, Australia

    Meg Harrold

  5. Royal Perth Hospital, Perth, WA, Australia

    Meg Harrold

  6. Latrobe University, Melbourne, VIC, Australia

    Anne Holland

  7. The Alfred Hospital, Melbourne, VIC, Australia

    Lorena Romero

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  1. Claire J. Tipping
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Correspondence to Carol L. Hodgson.

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Conflicts of interest

None of the authors have any financial conflicts of interest. Three of the authors (CT, MH and CH) are authors on one of the randomised controlled trials included in the review. The data extraction and risk of bias assessment for this study were completed by two independent researchers.

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Tipping, C.J., Harrold, M., Holland, A. et al. The effects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review. Intensive Care Med 43, 171–183 (2017). https://doi.org/10.1007/s00134-016-4612-0

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  • DOI: https://doi.org/10.1007/s00134-016-4612-0

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