Journal of Rehabilitation Medicine 51-10 | Page 79

Effect of physiotherapy for ICU-acquired muscle weakness
• Other neuromuscular or neurological disease and/or syn-
dromes causing weakness, e.g. Guillain–Barré syndrome,
myasthenia gravis, porphyria, Lambert- Eaton syndrome,
amyotrophic lateral sclerosis, vasculitic neuropathy, cervical
myelopathy and botulism.
• Severe physical co-morbidity before becoming critically ill
(e.g. frailty due to neurological conditions, and not able to
sit-to-stand or walk).
Interventions
All patients received individual rehabilitation from the first
day of admission to the post-acute ICU and rehabilitation
units. Rehabilitation included physiotherapy and occupational
therapy every weekday, for approximately 60 min for each type
of therapy, in addition other appropriate therapies. All patients
received individual treatment plans according to their individual
goals, such as regaining walking function and activities of daily
living (ADL). The content and intensity of therapies and ap-
proaches were, however, dependent on the severity of critical
illness and individual goals. It was not possible to measure the
content and amount of treatments in the early acute stage in the
ICU before discharge to our setting, although this information
would have been very important.
All therapists were trained and experienced in inpatient
rehabilitation. In order to collect all data about the content
and duration of physiotherapy and/or physical rehabilitation
applied at all stages of illness the content of physiotherapy
was documented daily in 5-min segments according to the phy-
siotherapy intervention categories shown in Table I (14). This
information was used to obtain a relatively precise picture of
the therapy provided in the daily physiotherapy sessions. It was
hypothesized that specific types of physiotherapy intervention
(measured as total time per week) might be related to achieving
independent walking.
Table I. Checklist for therapists to record the amount, intensity
and content of physical rehabilitation, such as type of physiotherapy
interventions, every working day
Physical rehabilitation Time per therapy
session (min)
Predominately active therapies
Assistive/active stance
Treadmill training
Electromechanical-assisted walking
Active breathing therapy
Strengthening exercises
Sit-to-stand exercises
Position shift exercises
Balance exercises in the sitting position
Balance exercises in a standing position
Conventional walking training
Stair training
Transfer training
Wheelchair training 5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
Predominately passive therapies
Passive mobilization into the stand
Patient positioning
Secretion mobilization
Passive/assistive movement
Stretching
Preparation and post-processing time in therapy
Physical thermal applications
Electrotherapeutic applications
Massage techniques and manual lymphatic drainage 5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
5 | 10 | 15| 20 | 25| 30
799
Measures and outcomes
The study protocol defined walking ability as the primary out-
come (14), with Functional Ambulation Categories (FAC) ≥ 3.
FAC ranges from 0 to 5, and was first described by Holden et al.
in 1984 (24). It provides a rapid visual assessment of walking,
is simple to use, easy to interpret, and distinguishes 6 levels of
walking ability on the basis of the amount of physical support
required (25), where 0 indicates a patient who is not able to
walk at all or needs the help of 2 therapists (non-functional
ambulator) and 5 indicates a patient who can walk everywhere
independently, including stairs (independent ambulator) (25).
All patients were followed up for 1 year or until FAC ≥ 3 was
reached, whichever was sooner. Time to achieve walking ability
was defined as the first time-point when walking was performed
successfully (time to event) (14). If a patient was discharged,
died or lost to follow-up this information was recorded. Subjects
were categorized as reaching FAC≥ 3 or not reaching FAC ≥ 3.
The following secondary outcomes were used:
• ADL measured with the Barthel Index (BI; 10 items; 0–100
points). The BI scale was chosen because it is the gold
standard measure in Germany to assess the progress of
rehabilitation.
• Clinical severity (e.g. mechanical ventilation, dysphagia,
tracheostomy) measured with the Early Rehabilitation Barthel
Index (ERBI) (26). The ERBI was used because this scale
is used in Germany to assess the severity of patients in early
rehabilitation.
• Muscle strength of the upper limb (shoulder, elbow and wrist)
and lower limb (hip, knee and ankle) using the Medical Re-
search Council (MRC) total score (22).
• Summed grip strength of both hands (measured with a dy-
namometer). Grip strength was used as a potential marker of
recovery from ICUAW (22, 27).
• Functional Status Score for the Intensive Care Unit (FSS-ICU)
(28). This scale was used because it was an important prog-
nostic factor in former analysis of patients with ICUAW (29).
• Pain using a numerical pain rating scale. Pain was measured
because it is a major impairment after ICUAW.
• “Functional reach” forward as a measure of sitting and stan-
ding balance (distance in cm). This scale was used because
it was an important prognostic factor in former analysis of
patients with ICUAW (29).
• Walking speed (m/s) and distance walked in 6 min (6-min
walk test; 6-MWT). These assessments were used to provide
important basic assessment for recovery of walking function
after ICUAW.
All assessments were administered by trained and experienced
therapists. The primary outcome was measured daily and se-
condary outcomes were measured from baseline (T0) every
2 weeks up to 8 weeks (T1, T2, T3, T4). Baseline (T0) was
defined as first admission to the post-acute hospital or inpatient
rehabilitation centre, respectively.
In addition, physiotherapists were asked after every single
treatment session to rate their subjective perception of physical
stress during the session on a visual analogue scale (VAS;
0–10), with 10 being the highest possible perceived physical
stress during treatment of patients. That question was included
because it was considered that performing physiotherapy for
patients with ICUAW might be exhausting for therapists. It
may be physically stressful because patients with ICUAW in the
post-acute phase may still be severely disabled and dependent
on devices, such as respirators and other medical equipment.
J Rehabil Med 51, 2019