Journal of Rehabilitation Medicine 51-10 | Page 78

798
S. Thomas et al.
there are fewer studies of chronic critically ill patients
(12), defined as > 21 days ICU-treatment including more
than 6 h of mechanical ventilation daily (13, 14).
The amount, intensity and frequency of physical
rehabilitation is regarded as an important part of mo-
toric recovery, such as regaining walking, e.g. after
stroke (15, 16). Overall, it is suggested that increasing
the intensity of, and time spent in, rehabilitation may
have favourable outcomes (17). Some studies have
described the content and amount of physical rehabi-
litation and applied therapies for people with ICUAW.
For example, in 2012 Berney et al. described the goals
and detailed interventions, such as manual hyperinfla-
tion, positioning and manual techniques of respiratory
physiotherapy management in the acute phase in the
ICU in Australia (18). In a recently published cohort
study out-of-bed rehabilitation in 4 metropolitan hos-
pitals was described (19). The authors concluded that
out-of-bed rehabilitation was not commonly provided
in patients who presented with ICUAW (19).
Another example is the approach of early mobiliza-
tion in critically ill adults (20). In a survey in academic
ICUs in Canada (20) both physicians and physio­
therapists underestimated the incidence of ICUAW and
felt inadequately trained to mobilize patients receiving
mechanical ventilation.
All of these studies, however, described current
practice in the acute and subacute hospitals or subacute
weaning centres. However, little is known about the
interventions that physiotherapists apply during post-
acute inpatient rehabilitation in chronic critically ill
patients with ICUAW.
In 2019, Schreiber et al. found that patients who
achieved more demanding programme steps in phy-
siotherapy showed higher weaning success, and that
physiotherapy interventions were an important pre-
dictor of successful weaning (21). However, there is a
lack of studies that describe the specific contents and
type of physical rehabilitation and applied therapies in
people with ICUAW who are chronically critically ill
and there is no evidence-based standard for what type
of therapy interventions should be mandatory.
To date, there is no published research on the influ-
ence of time, intensity, frequency, type and amount
of rehabilitation interventions in chronic critically ill
people with ICUAW.
The aim of this study was therefore to describe all
physiotherapeutic interventions during post-acute in-
patient rehabilitation for chronic critically ill patients
with ICUAW.
The hypothesis for this study was that specific types
of physiotherapy in the rehabilitation of chronic criti-
cally ill patients with ICUAW might be related to the
achievement of independent walking.
www.medicaljournals.se/jrm
Furthermore, from the clinical point of view, mobi-
lizing seriously ill persons may be stressful for physio­
therapists and therefore the type of interventions chosen
may be limited to less-demanding modalities. To our
knowledge there has been no research into people with
ICUAW who are chronic critically ill. A secondary
aim of the current study was therefore to evaluate the
perceived stress levels among physiotherapists during
therapy of patients with ICUAW.
METHODS
Study design
Data were collected as part of a single-centre cohort study that
aimed to describe the time course of recovery of patients with
ICUAW.
The study was conducted according to the Declaration of Hel-
sinki and approval was obtained from the local ethics commission
(Sächsische Landesärztekammer, EK-BR-32/13-1/106755). The
study was registered prior to publication (German Register of Clini-
cal Trials, DRKS00006528). The STrengthening the Reporting
of OBservational studies in Epidemiology (STROBE) guidelines
were followed in performing this study and writing this paper.
Patients and setting
All patients admitted to the post-acute ICU, weaning and early
rehabilitation departments, Klinik Bavaria Kreischa, Germany,
between January 2013 and March 2015 were screened (14). The
post-acute department integrates specialized weaning and mobi-
lization and rehabilitation approaches for patients immediately
after discharge from the acute stage and ICU hospitals. Patients
in this cohort were admitted to this setting after an acute ICU
treatment of more than 3 weeks, e.g. carried over transferred
from University Hospital Dresden.
Based on the inclusion and exclusion criteria listed below,
patients were recruited to the post-acute rehabilitation depart-
ment, as described previously (14).
Inclusion criteria
• Patient is in the post-acute phase and is chronically critically
ill, defined as > 21 days ICU-treatment including mechanical
ventilation and at least 14 additional days of ICU treatment
(13, 14).
• ICUAW, defined as a Medical Research Council (MRC) total
score (upper and lower limb) < 48 points (22).
• Muscle weakness pathology, e.g. a clinical diagnosis of
critical illness myopathy (CIM) and/or critical illness poly-
neuropathy (CIP).
• Aged 18 years or older.
• Richmond Agitation Sedation Scale (RASS) score of –1 to
2 (23).
• Written informed consent of the patient or his/her legal
guardian.
Exclusion criteria
• Patients receiving palliative care.
• Co-morbidities of the trunk or lower limbs interfering with
upright posture and walking (e.g. amputation or fracture of
lower limb).