Journal of Rehabilitation Medicine 51-11 | Page 67

Cochrane Corner
•
should include assessments by healthcare profes-
sionals experienced in critical care and rehabilitation.
For patients at risk, agree short-term and medium-
term rehabilitation goals, based on the comprehen-
sive clinical assessment. The patient’s family and/or
carer should also be involved.
However, evidence to support these guidelines is
currently still very limited. They did propose a list of
research questions such as:
• Which therapeutic strategies are the most clini-
cally and cost effective at reducing the prevalence
and severity of critical illness-associated physical
morbidity, psychological morbidity and cognitive
dysfunction or at reducing the magnitude of critical
illness-associated physical morbidity, psychological
morbidity and cognitive dysfunction?
In the last decade, several Cochrane Reviews have
been published regarding the prevention and treatment
of critical illness neuro- and/or myopathy and PICS at
large of which we give a short overview.
In 2014, a Cochrane Review on interventions for
preventing critical illness polyneuropathy (CIP) and cri-
tical illness myopathy (CIM) showed moderate-quality
evidence suggesting a potential benefit – shorter duration
of mechanical ventilation – of early rehabilitation on CIP/
CIM. Very low-quality evidence suggested no effect of
electrical muscle stimulation (7).
Two Cochrane Reviews were published in 2015 on
rehabilitation for patients with critical illness. The first
one focused on physical rehabilitation interventions for
in- and outpatients with CIP/CIM, in the acute as well as
the chronic phase. Unfortunately, the authors had to con-
clude that there were no published RCTs or quasi-RCTs
that examine whether physical rehabilitation interventions
improve activities of daily living for people with CIP/CIM
(8). The second one assessed the effectiveness of exercise
rehabilitation programmes, initiated after ICU discharge,
for functional exercise capacity and HRQoL in adult ICU
survivors (9). An overall result for the effects of exercise-
based interventions could not be determined. Three studies
reported improvement in functional exercise but 3 others
found no effects of treatment. A third review published in
2018 studied the effects of early intervention (mobiliza-
tion or active exercise), commenced in the ICU, provided
to critically ill adults, on improving physical function or
performance, muscle strength and HRQoL. Currently
there was only low-quality evidence for the effect, more
specifically (in one study) getting out of bed earlier and
walking a greater distance, but no effect on number of daily
activities they could perform (10). Another very recently
published systematic review found that enhanced physical
rehabilitation following ICU discharge may make little
or no difference to quality of life or mortality (11). Two
other non-Cochrane reviews concluded on positive effects
881
of early rehabilitation on muscle strength and functional
status, even if they also advise further research to improve
quality of evidence (12, 13).
Concerning psychological symptoms such as anxiety
and depression a Cochrane Review from 2014 found
minimal evidence from RCTs of the benefits or harms of
patient diaries for patients and their caregivers or family
members. A small study has described their potential to
reduce post-traumatic stress symptomatology in family
members. However, there is currently inadequate evi-
dence to support their effectiveness in improving psy-
chological recovery after critical illness for patients and
their family members (14). The authors of a more recent
Cochrane Review, from 2018, were uncertain of the ef-
fects of information or education interventions given to
adult ICU patients and their carers, as the evidence in all
cases was of very low-certainty (15).
So in summary, even though guidelines recommend
early rehabilitation during as well as after a stay in the
ICU for critically ill adults, robust evidence on the ef-
fectiveness is still lacking. This may change in future
updates as several studies are ongoing. As Brown et al.
(16) state, the complexity of the health states associated
with PICS suggests tha t careful and rigorous evaluation
of multidisciplinary, multimodality interventions – tied
to the specific conditions of interest – will be required
to address these important problems.
ACKNOWLEDGEMENTS.
The author thanks Cochrane Rehabilitation and Cochrane Ef-
fective Practice and Organisation of Care Group for reviewing
the contents of the Cochrane Corner.
The author have no conflicts of interest declare.
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