We know that our critically ill patients get debilitated and weak and that it happens within days in critical illness. Because of this, we try to provide some form of physical therapy to these patients, although the ordering and administration of this physical therapy is inconsistent at best. Providing physical therapy makes sense. If patients are getting debilitated because they are lying in bed for prolonged periods of time, helping them at least move and use their muscles, and even potentially sitting up or walking may preserve some of their strength and/or attenuate some of the weakness. Furthermore, upright positioning is good for pulmonary function, increasing both tidal volume and pulmonary clearance of secretions. Unfortunately, providing physical therapy to our ICU patients is hard. Sometimes the ICU has a dedicated physical therapist. Other times they share a physical therapist with other areas of the hospital and more of the responsibility for physical therapy falls to the bedside nurse. A few institutions place a higher importance on physical therapy, and actually have mobility protocols in their ICUs, which facilitate at least sitting critically ill patients at the edge of the bed or walking them in the hallways (many of whom are mechanically ventilated). This level of physical therapy is very resource intensive, often requiring three or four nurses, a couple of physical therapists, and a respiratory therapist or two. Because of this, most hospitals did not do this for their patients.
Then in 2008, Morris and colleagues published a very provocative study conducted in the Intensive Care Units at Wake Forest. This study allocated patients based on the ICU they were being cared in to either passive range of motion by the bedside nurse or an early mobility protocol. In the early mobility group, the study had a dedicated mobility team (not involved in patient care) who initiated physical therapy as a standing order on patients within 48 hours of their admission to the ICU (Morris PE, et al. Crit Care Med. 2008;36(8)2238). This intervention not only got patients out of bed earlier, but also significantly reduced ICU and hospital lengths of stay. And all of this was done without increased incidence of complications or cost (even when factoring in the cost of the mobility team). As you can probably imagine, the study created a lot of buzz about the potential benefits of early mobility.
This was followed in 2009 by the publication of another provocative study (Schweickert WD, et al. Lancet. 2009;373(9678):1874-1882). This two-center trial randomized 104 patients to early PT and mobility with daily awakening trials versus daily awakening trials. The study demonstrated an improved incidence of return to independent functional status after hospital discharge, shorter duration of delirium and more days alive and off the ventilator. Impressive findings, albeit from a small study.
These two studies generated enthusiasm in many ICUs around early mobility and even dedicated mobility teams. My ICU was one of these that was excited about trying to provide this to our patients. Unfortunately, this is not easy to do – it is very resource intensive, specifically requiring dedicated physical therapists and lots of nursing effort. Implementation has been slow and painstakingly difficult.
And then – Whoa! Pump The Brakes.
In the last 4 months, two new studies have been published that haven’t replicated the previously demonstrated benefits. In a randomized study published in the blue journal, Moss and colleagues didn’t find any significant improvement in long-term physical function at either 1, 3 or 6 months post hospital discharge from intensive physical therapy compared to standard physical therapy (Moss M, et al. Am J Respir Crit Care Med. 2016;193(10):1101-1110). While this study has received criticism about the nature and intensity of the physical therapy in the intervention group (it wasn’t really early mobility), it still raised some questions about the overall panacea that many were espousing for early mobility.
In addition, last month, the investigators from Wake Forest, the same investigators who conducted one of the earlier studies demonstrating benefit, published the results of their follow-up trial of early mobility (Morris PE, et al. JAMA. 2016;315(24):2694-2702). While still single center, this trial randomized 300 critically ill patients to either standard physical therapy / rehab or early intensive physical therapy and rehab. The early intensive physical therapy was again administered by a dedicated team seven days a week, but this time at an increased frequency of thrice daily. Unfortunately, the results did not replicate the previous study. In this study, intensive physical therapy and early mobility did not significantly improve 2,4, or 6 month outcomes, nor did it shorten hospital or ICU lengths of stay.
Many believers have questioned some aspects of this trial – were the patients too sedated? Was the physical therapy intervention the right intervention? Did the investigators have the right experience and study team? While I think understanding the study results and the conditions of the study is important, I also think these are the wrong questions. This trial was done in the same hospital ICUs by the same investigators as one of the previous trials which the believers continue to herald. These investigators were not novice at this intervention, and in fact, many think they are among the world’s leaders in ICU rehab and physical therapy. These results are valid – intensive physical therapy did not improve outcomes of these critically ill patients.
What do these results mean to me? I still think early intensive physical therapy in critically ill patients may have benefit. But I think this most recent trial shows us that it doesn’t benefit every critically ill patient, and that we shouldn’t spend considerable time implementing it in full force for all our patients. I think we should focus future efforts on defining the population that truly benefits from this – is it our sickest, most inflamed patients? Or are they so inflamed that early physical therapy isn’t helpful? Is it younger patients with better baseline function, or older patients who are a bit compromised even prior to ICU admission? Are there specific disease states this is more likely to help in? I believe these are the important questions to be asked and once the answers are found, we can potentially focus our efforts (and this labor intensive intervention) toward the patients most likely to benefit.
P.S. I hope to add some additional thoughts from Drs. Moss and Morris about their two recent studies in the near future.