Rehabilitation for People With Critical Illness: Taking the Next Steps

The Current State

Improvements in managing the care of patients with critical illness have resulted in an increasing number of survivors.¹ However, survivors of critical illness often experience “post–intensive care syndrome,”² with long-lasting physical impairments, including muscle weakness and decreased functional ability³ and neuropsychiatric dysfunction.⁴ These consequences of critical illness often lead to decreased quality of life.^5,6

Early intervention by physical therapists and other rehabilitation and critical care professionals is feasible and safe for patients in respiratory,⁷ medical,⁸ and surgical⁹ ICUs. Moreover, early rehabilitation in the ICU is associated with many short-term benefits, including decreased duration of mechanical ventilation, shorter ICU and hospital lengths of stay, shorter duration of delirium, and improved functional outcomes.^8,10–12 Throughout a 1-year follow-up, early rehabilitation during the ICU stay also is associated with decreased hospital readmission and mortality rates.¹³

With this growing body of evidence, interest in early rehabilitation in the ICU is rapidly increasing, likely resulting in significant change from a 2007 survey that demonstrated substantial inconsistency in ICU-based practice among acute care physical therapists.¹⁴ Despite the increase in early rehabilitation interventions, however, many survivors of critical illness still have functional limitations after discharge from the ICU.^3,15 Rehabilitation following critical illness, therefore, is increasingly acknowledged as an area of clinical importance.^16,17

The content in this series also suggests the emergence of rehabilitation as an integral part of critical care medicine. Rehabilitation professionals are key members of interprofessional teams in inpatient rehabilitation,¹⁸ geriatrics,¹⁹ and pain management,^20–21 and the interprofessional team is becoming increasingly recognized as an important component of ICU services.²² With an emphasis on function and a biopsychosocial orientation, rehabilitation professionals can contribute to team effectiveness as engaged, constructive team members in addition to being providers of specific interventions, thereby optimizing comprehensive care for these complex patients. Indeed, characteristics of team functioning predict stroke outcomes,²³ and enhanced team functioning is associated with better patient outcomes.²⁴

The Challenge

The challenge for the rehabilitation and critical care community is 3-fold. First, we must continue developing effective rehabilitation interventions in the management of patients with critical illness while they are in the ICU and beyond. Second, we must increase awareness of “post–intensive care syndrome,” helping our colleagues in acute care, subacute rehabilitation, skilled nursing, outpatient, and home care settings to recognize the clinical presentation and understand the role of critical illness in these functional impairments.² Third, we must endeavor to be committed members of interprofessional health care teams and promote collaborative practice across all health care settings. We hope that articles in the 2 issues of this special series will provide our readership with an enhanced understanding of, and new management strategies for, the many physical and cognitive challenges facing survivors of critical illness so that this unique and complex patient population achieves improved outcomes.

This Issue

• With growing recognition of the efficacy of rehabilitation interventions for survivors of critical illness, it is important to identify evidence for best practice across the continuum of care. Harabin and Kiley,²⁵ from the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH), discuss the role of the NIH in general—and the NHLBI in particular—in providing funding for research initiatives that examine strategies aimed at improving outcomes for survivors of critical illness. NHLBI encourages high-quality, investigator-initiated research grant applications as an effective way to increase support for such research.

• An excellent overview of ICU-acquired weakness is provided by Nordon-Craft and colleagues.²⁶ They describe current diagnostic criteria, medical management, and prognosis and present guidelines for identifying patients with critical illness for whom rehabilitation interventions are safe and feasible. The authors also review specific measurement tools, organized according to the International Classification of Functioning, Disability and Health (ICF),²⁷ and discuss physical intervention strategies.

• Many survivors of critical illness have persistent functional limitations following hospital discharge. Denehy and colleagues²⁸ investigated physical activity levels of older adult survivors of critical illness 2 months after discharge from the ICU and found that their physical activity levels were lower than those reported in older adults who were healthy. The authors explore the factors that may be associated with reduced activity levels in this patient population.

• Because physical impairments and functional limitations persist following ICU discharge, the importance of continuing rehabilitation after discharge has become increasingly apparent. Hopkins and colleagues²⁹ examined rehabilitation service delivery following ICU discharge. They found decreased physical activity and mobility on the ward relative to the ICU, despite the presence of requests for physical therapy consultation or orders for nursing to ambulate at the time of the patient transfer. The authors discuss their findings in light of the importance of a hospital-wide culture that values patient activity.

• Developing an exercise program with the appropriate intensity for people who are critically ill can be challenging for physical therapists. Berney and colleagues³⁰ investigated an exercise training rehabilitation program that commenced in the ICU, continued to the acute care ward, and was subsequently delivered for 8 weeks in the outpatient setting. The authors found that rehabilitation interventions guided by an objective exercise prescription were safe and feasible; however, outpatient patient participation was low, and they suggest that investigations of rehabilitation delivery models that maximize patient participation are warranted.

Three articles describe the use of outcome measures for documenting changes in function for survivors of critical illness and for predicting discharge destinations:

• Thrush and colleagues³¹ examined the utility of the Functional Status Score for the Intensive Care Unit (FSS-ICU) in measuring changes in physical function and predicting discharge destination in patients at a long-term acute care hospital. The FSS-ICU scores differed between discharge destinations, and the authors discuss the potential use of this outcome measure in discharge planning.

• Lee and colleagues³² evaluated the ability of manual muscle testing and grip strength to predict in-hospital mortality, duration of mechanical ventilation, and ICU and hospital lengths of stay. Their findings indicate that manual muscle testing was superior to grip strength for these predictions in their surgical ICU population.

• Alison and colleagues³³ investigated the Six-Minute Walk Test (6MWT), an outcome measure that is valid and reliable in a number of patient populations, in survivors of critical illness. Based on their findings, they provide considerations for the home administration of the 6MWT for this patient population to ensure reliability of the test.

Finally, we are pleased to include 2 articles that report study protocols. This is a new manuscript category for PTJ. Publishing study protocols highlights active, registered research studies, thereby enabling scientists and funding agencies to stay current in their fields. These publications serve to prevent study duplication and potentially encourage collaboration. Furthermore, transparency is increased with these publications because more detailed information about the design and protocol of the study is included compared with a trials registry. The greater detail allows deviations in the protocol that occurred while conducting the study to be recognized when reviewing reports of the study's results. In this issue:

• Kho and colleagues³⁴ describe their study protocol for investigating the hypothesis that neuromuscular electrical stimulation (NMES), applied to 3 bilateral lower-extremity muscle groups, will increase lower-extremity strength in individuals with critical illness who are mechanically ventilated. This randomized, single-blinded, sham-controlled intervention study, when completed, has the potential to determine whether NMES is a feasible and efficacious approach for the management of ICU-acquired weakness.

• Brummell and colleagues³⁵ present the protocol of a study designed to determine if early and sustained cognitive rehabilitation can be combined with physical rehabilitation, and if this combination will improve the recovery of cognitive and physical functioning. Individuals with critical illness will be randomized to 1 of 3 groups: usual care, physical rehabilitation, or cognitive rehabilitation plus physical rehabilitation. Cognitive and physical functioning will be evaluated 3 months following hospital discharge.

The outcomes of both of these studies will inform the development of novel rehabilitation strategies for this patient population.

Special Thanks

This special series is the culmination of the efforts of many individuals. The enthusiasm and steadfast support from Editor-in-Chief Rebecca Craik and Deputy Editor Dan Riddle is greatly appreciated. The efficient management of these manuscripts could not have been accomplished without the exceptional contributions of PTJ's Editorial Office. Finally, we would like to acknowledge the 51 reviewers (see next page) who applied their expertise (and countless hours) to provide important feedback that contributed to the high quality of these manuscripts.