Journal of Rehabilitation Medicine 51-10 | Page 82

802
S. Thomas et al.
of walking function was found and, in these patients
with ICUAW, physiotherapy interventions were
identified that might be correlated with achieving this
important activity. If, in the first 2 weeks, walking
activities overground or assisted walking was used
in physiotherapy then it was more likely that patients
would achieve independent walking. Patients who
did not regain walking ability received predominately
passive interventions from physiotherapists in the
first weeks of rehabilitation. Walking and sit-to-stand
exercises and balance manoeuvres in sitting were the
most often used interventions in the rehabilitation of
patients with ICUAW.
The results of this study can be summarized as fol-
lows: chronic critically ill persons in the post-acute
phase benefit from early mobilization, task-oriented
walking, muscle training of the lower extremities (e.g.
sit-to-stand training) and balance activities in standing.
Patients receiving passive treatment are less likely to
regain walking ability. In addition, it has been shown
that severely affected patients tolerate the frequency,
time and intensity of the same exercises (35).
Overall, there has been little research on specific
aspects of rehabilitation interventions with respect
to time, intensity, frequency and amount in chronic
critically ill people with ICUAW. This study could
therefore been regarded as a first step in describing
physiotherapeutic interventions in patients with
ICUAW during inpatient rehabilitation.
The subjectively perceived physical stress among
physiotherapists during therapies was 4 out of 10 marks
in the mean load on a scale of 1 to 10 and in stress levels
between physiotherapists who treated patients who
regained or did not regain walking ability. These results
may indicate that the therapists were experienced and
used their tacit knowledge, since there is little research
into stress levels, especially in patients with ICUAW.
Johnson et al. recently described a retrospective
pre-/post-subgroup analysis in 114 acute critically ill
cardiovascular patients with a mean daily treatment
time at baseline of 51.7 min and a mean frequency
of treatment in the ICU of 0.59 per day (36). Their
analysis showed that an increased amount of therapies
resulted in shorter length of stay.
The chronic critically ill patients in the current study,
however, received physiotherapy every working day
at a relatively high level, given that the patients were
very severely affected and, in some cases, still not
weaned from the respirator. This could, however, be
due to the fact that the patients had a lower APACHE
II score (which provides information about severity) at
baseline with a median of 16 out of 34 points compared
with Johnson et al. with a mean of 20 out of 34 points.
However, comparable with our study, Johnson et al.
www.medicaljournals.se/jrm
described highly active therapies, such as sit-to-stand
transfers and marching on the spot (36), and used a
clinical decision-making flowsheet for progression.
As discussed by Tyson et al. in 2018, it appears to be
important that physiotherapists (re)organize treatment
sessions in order to maximize the intensity of practice
of functional tasks (37).
Study limitations
This study has a number of limitations. The cohort
study design means that no conclusion can be drawn
regarding a causal relationship between walking time
in therapy and walking ability achieved. Although the
study found that more therapy time was spent with
walking in those patients who regained good walking
function, this is only an correlation. In addition, some
patients in this study may have been too severely affec-
ted to be able to participate in any gait training. Future
studies should therefore use randomized controlled
study designs to explore causal relationships between
the content and dose of interventions and the likelihood
of regaining walking ability (12, 38). However, the cur-
rent study indicates that walking training, in particular,
is correlated with regaining walking ability, which is
in line with current knowledge (35).
A recent Cochrane Review, however, described the
lack of randomized trials of people with ICUAW with
a defined diagnosis of CIP or CIM (39), indicating that
little is known about which therapies are effective.
Randomized trials with a detailed description of in-
tensity and frequency of physiotherapy interventions
are therefore warranted in people with ICUAW with a
defined diagnosis of CIP and/or CIM. The content and
amount of treatments in the very early acute stage before
the rehabilitation stay were not measured in the current
study. It is unclear how this might have influenced the
outcome. Future cohorts should measure the start, con-
tent and amount of treatments at all stages of recovery.
It can be argued that the primary diagnosis, the cause
of acute ICU treatment, might affect the outcome of
walking training. However, in a previous analysis we
showed that the severity after the ICU stay, rather than
the cause of the illness, might be the more important
prognostic factor (33).Only those patients who were
able to perform our a priori defined assessments were
included in the current cohort study. The study might be
therefore limited by excluding some sedated or very agi-
tated patients, and therefore may limit generalizability of
the results to the entire chronic critically ill population. In
addition, the diagnosis of CIP and CIM as a major cause
of acquired muscle weakness is argued to need clinical
and electrophysiological investigations (40). A possible
limitation is therefore that we did not always perform