Abstract
Background and Purpose Although the benefits of early mobilization in the intensive care unit (ICU) have been well documented in recent years, the decision-making process and customization of treatment strategies for patients with ICU-acquired weakness have not been well defined in the literature. This case report will describe a patient with ICU-acquired weakness in the long-term acute care hospital (LTACH) setting and mobilization strategies that include novel devices for therapeutic exercise and gait training.
Case Description A 73-year-old, active woman underwent a routine cardioversion for atrial fibrillation but developed multiple complications, including sepsis and respiratory failure. The patient spent 3 weeks of limited activity in the ICU and was transferred to our LTACH for continued medical intervention and rehabilitation. A 4-phase graded mobilization program was initiated in the LTACH ICU. Within that program, the physical therapy interventions included partial weight-bearing antigravity strength training with a mobile leg press and gait training with a hydraulic-assist platform walker.
Outcome Before interventions, the patient had severe weakness (Medical Research Council [MRC] sum score of 18/60) and displayed complete dependence for all functioning. She progressed to being able to ambulate 150 ft (1 ft=0.3048 m) using a rolling walker with accompanying strength increases to an MRC sum score of 52/60.
Discussion This case report describes novel mobility strategies for managing a patient with ICU-acquired weakness. The application of a graded mobilization program using a mobile leg press and a hydraulic-assist platform walker was safe and feasible, and appeared to expedite the patient's recovery process while decreasing the amount of manual lifting for the therapists.
As medical technology continues to improve, more patients are surviving critical illness and trauma that were once considered beyond treatment. Historically, patients with critical illness have been placed on bed rest for the majority of their stay in the intensive care unit (ICU) with little or no physical therapy because of concerns that patients in the ICU were “too sick” to participate in physical activities or to tolerate the metabolic demands of activity. The preservation of muscle strength and functioning was a secondary concern to stabilization of the patient.
The complications associated with bed confinement have long been recognized to include postural hypotension, bone demineralization, contractures, skin breakdown, and pneumonia, as well as a sense of helplessness for the patient.1 Recent evidence has clarified the severity of those impairments and added additional concerns that include muscle weakness, systemic inflammation, atelectasis, insulin resistance, and thromboembolic disease.2 Some of the most devastating changes of immobilization occur in the musculoskeletal system. Prolonged immobilization results in muscle atrophy and a rapid loss of strength, especially in the large lower-extremity muscle groups. Studies on the effects of bed rest have revealed that the antigravity leg muscles are the first to weaken during inactivity and may decline as much as 3% per day in individuals who are healthy.3–5
In addition to the anticipated weakness that accompanies inactivity, a patient with prolonged critical illness is at risk for developing ICU-acquired weakness.6–8 The presence of multiple organ failure, muscle inactivity, and hyperglycemia, and the receipt of corticosteroids and neuromuscular blockers may be associated with an increased risk for ICU-acquired weakness.9 Intensive care unit–acquired weakness may be due to critical illness polyneuropathy (CIP), critical illness myopathy (CIM), or a combination of CIP and CIM,10 which is sometimes called “critical illness neuromyopathy.”8 Intensive care unit–acquired weakness presents as symmetrical weakness in the muscles of the extremities and trunk6,8,11 and in the muscles for respiration.12,13 Recent evidence implicates myosin loss, due to a combination of decreased muscle protein synthesis and increased proteolysis, as the cause of weakness.14
Persistent weakness may contribute to decreased functioning well beyond the acute and subacute phases of illness. Research into the sequelae of acute respiratory distress syndrome (ARDS) requiring a stay in an ICU provided insight into long-term implications and the persistent impairments that follow critical illness. Herridge et al15 reported that 5 years after surviving ARDS, even relatively young people had reduced exercise capacity that may have resulted from persistent weakness, as well as persisting physical and psychological impairments. Although there has been growing evidence about ICU-acquired weakness, there has been no compelling evidence that pharmacologic or rehabilitation therapies can accelerate recovery from weakness.16 Therefore, prevention of the evolution of weakness and restoration of strength through physical therapy interventions that foster muscle activation and physical activity have recently been promoted in the literature.7,17,18
There is growing evidence of the safety, feasibility, and benefits of exercise interventions and early mobilization of patients while in the ICU.17–20 However, the implementation of these interventions requires decision making to determine the mode, intensity, and duration of the interventions. For example, Morris et al21 developed a protocol for early mobilization of patients with acute respiratory failure that standardized the physical therapy interventions and frequency. They applied an algorithm that methodically advanced activity and physical demands based on the patient's strength and response to activity. Interventions in the algorithm started with passive range-of-motion exercises and progressed to sitting and ambulating with a walker, based on the patient's response to the interventions.
In our experience, the diversity of pathology and accompanying physical impairments among patients with critical illness provides a considerable challenge to the decision making required of the physical therapist practicing in the ICU. For example, one concern when dealing with severely weak patients is the profound increase in activity intensity when they advance from sitting on the edge of the bed to standing and accepting full body weight through the lower extremities. The effort required for severely weak patients to stand is often underestimated, because this activity requires considerably more muscle strength and metabolic demand than sitting activities. These patients often require maximal assistance during the sit-to-stand activity, and they can reach exhaustion within seconds. Many patients may not be able to stand at all due to orthostatic intolerance or the amount of strength required from the trunk and leg muscles. The difficult transition from sitting to standing also can be physically taxing on the caregiver, as well as psychologically degrading for the patient. Frustration, low self-efficacy, and depression often occur during this phase of recovery due to the patient's dependence on assistance from others to move.
To provide a more orderly transition from bed rest to assisted ambulation for the patient with critical illness, new rehabilitation technologies were added to the 4-phase program described by Morris et al.21 Additional interventions included a mobile leg press for partial weight-bearing, antigravity exercise and a hydraulic-assist platform walker for gait training (Tab. 1).
Graded Mobilization Programa
The mobile leg press (Moveo XP, DJO Inc, San Diego, California) resembles a traditional tilt table but is modified with a sliding carriage, which tracks in a set of guide rails on the table's surface. The mobile leg press is used in the following manner: the device is placed next to the patient's bed, and the patient is transferred laterally with a draw sheet to the carriage with the lower extremities positioned on a support pad. A safety strap is fastened around the patient's waist, and the head of the carriage is elevated for comfort. It has been proposed that this upright position enhances respiration by enabling diaphragm movement,22 and we have observed improved mental alertness. While the carriage is unlocked, the table is gradually tilted toward an angle of elevation until the patient can perform a controlled leg press on the platform against resistance, which is graded based on the amount of inclination. The leg press exercise is defined as slowly allowing the knees to flex to approximately 60 degrees and then return to a position of full knee extension. A stopping pin in a series of holes can limit carriage travel (squat depth), and a speed controller prevents excessive speed of the carriage. The amount of force that the patient exerts to fully extend the knees depends on the incline of the table. For example, at a 15-degree incline, the patient lifts approximately 30% of her or his body weight; at a 35-degree incline, the patient lifts approximately 75% of body weight.23,24 These calculations were determined by placing a calibrated spring scale under the patient's feet at varying inclines on the mobile leg press.24
The rationale for using the leg press in the mobility program is that after prolonged bed rest, partial weight-bearing activities are needed to increase the strength of the antigravity muscles. Weight-bearing, or “closed-chain,” exercises provide optimal resistance for strengthening, facilitate co-contractions of several muscle groups (both prime movers and stabilizers), elicit eccentric muscle contractions, and stimulate joint proprioceptors.25 The decision to encourage weight-bearing activities is supported by the findings recently reported by Belavý et al, who concluded that among patients on bed rest, “such deconditioned patients should be prescribed ‘closed-chain’ simulated resistance exercises, which target the lower-limb antigravity extensor muscles which were most affected in bed rest.”26(p489)
Another adjunctive technology in the graded mobility program is the use of a standing transfer device (Sarah Plus, ArjoHuntleigh, Eslov, Sweden), which was converted into a hydraulic-assist platform walker by taking off the removable knee block and footplate. This type of platform walker has powered hydraulic capabilities to assist with lifting the patient from a sitting to a standing position in an arc-like fashion, instead of a vertical up and down movement seen with conventional platform walkers. This arcing movement pattern was chosen to replicate the natural movement during typical sit-to-stand activities. The hydraulic-assist platform walker allows a patient to place weight through the elbows and forearms, instead of the hands. Our observation is that after prolonged bed rest, patients experience difficulty using a standard walker to assist with standing and ambulation secondary to the deterioration of grip strength27 and elbow extension strength that accompanies ICU-acquired weakness. In our experience, use of the hydraulic-assist platform walker allows patients to reduce the load on the legs by relying on upper body support, thereby allowing them to stand for longer periods of time and with less physical assistance by the physical therapist.
The literature has described protocols and guidelines for early mobility in the ICU17–21,28; however, the reports have not described how these exercise interventions were customized to the unique needs of each patient. The purpose of this case report is to describe the series of clinical decisions and implementation of a graded mobilization program that includes partial weight-bearing, antigravity exercise and the use of a hydraulic-assist platform walker.
Patient History and Review of Systems
The patient was a 73-year-old, socially active woman who was functioning independently in the community and participated in a daily exercise program of water aerobics and weight training. She had a past medical history of hypertension and atrial fibrillation. The patient underwent a routine outpatient cardioversion for atrial fibrillation but developed multiple complications, requiring admission to the ICU the following day. Post-cardioversion sequelae included multilobar pneumonia, sepsis, and respiratory failure requiring mechanical ventilation. A physical therapy consultation was requested on day 11 of the patient's stay in a short-term acute care hospital (STACH) ICU, and an examination was performed by a physical therapist. The therapist concluded that the patient would benefit from passive range-of-motion (ROM) exercises every shift administered by nursing personnel. Passive ROM exercises were carried out by nursing personnel for the remaining 10 days of her STACH stay. The patient underwent a tracheostomy to accommodate continued mechanical ventilation and was transferred to our long-term acute care hospital (LTACH) ICU for weaning from the ventilator and rehabilitation. The transfer occurred on day 21 of her hospitalization.
Clinical Impression
The patient appeared to be a candidate for our physical therapy program for mobility activities because she was awake, had muscular weakness, was dependent for all mobility skills, and was independent prior to the hospital admission. The plan for the examination was to measure the patient's ability to follow commands, joint ROM, muscle strength using the Medical Research Council (MRC) sum score, sensation, sitting balance, and ability to perform functional activities. The MRC sum score quantifies global muscle strength by measuring the strength of 6 muscle groups bilaterally (3 in the upper extremities and 3 in the lower extremities). A score between 0 (no muscle movement) and 5 (normal strength) is assigned to each muscle group, which renders a maximum total score of 60.29 The MRC sum score has been validated and is reliable for patients with critical illness.29
Examination
On examination by the physical therapist at the LTACH, the patient was alert, followed simple commands, communicated effectively with head nods and mouthing words, and had marked muscular atrophy. She required mechanical ventilation via tracheostomy and was on continuous positive air pressure mode with fraction of inspired oxygen (Fio2) of 0.45. At rest, her blood pressure was 112/65 mm Hg and heart rate was 74 bpm with sinus rhythm. Manual muscle testing revealed absent (0/5) dorsiflexion, trace (1/5) shoulder abduction, and poor (2/5) symmetrical strength of hip flexion, knee extension, elbow flexion, and wrist extension. The MRC sum score for the patient was 18, which indicated “severe muscle weakness” (MRC sum score <36).29 Quadriceps, Achilles' tendon, and biceps brachii deep tendon reflexes were diminished, and sensory testing revealed impaired sensation to light touch and sharp or dull for the upper and lower limbs in a stocking-glove distribution.
Functioning was sufficiently limited, and we could not identify a standardized measure of function that could distinguish her limitations while measuring her abilities (due to the floor effect). Therefore, examination of functioning required that the therapist assist the patient to perform tasks or activities and then determine the extent of assistance the patient required. The amount of assistance provided information on the ranking of the patient's performance (Appendix). Rolling in bed and sitting at the edge of bed required maximal assistance from 2 therapists. Fatigue and dizziness (blood pressure drop to 92/60 mm Hg) initially limited her tolerance of supported sitting to 30 seconds. She was incapable of sitting without manual assistance from the therapist, who provided maximal assistance. Standing was deemed unsafe at this time due to orthostatic intolerance, insufficient trunk control, and severe weakness in the lower extremities. The patient's stated goal was “to be able to walk again” and return to an independent level of function.
Clinical Impression
The patient exhibited profound muscular weakness, dependence for all functioning, and difficulty weaning from mechanical ventilation. She met the diagnostic criteria for ICU-acquired weakness, as established by Stevens et al:
“Generalized weakness developing after the onset of critical illness
Weakness is diffuse (involving both proximal and distal muscles), symmetric, flaccid, and generally spares cranial nerves
MRC sum score <48 or mean MRC score, 4 in all testable muscle groups noted on ≤2 occasions separated >24 hours
Dependence on mechanical ventilation
Cause of weakness not related to the underlying critical illness has been excluded (minimal criteria for diagnosing ICU-acquired weakness: 1, 2, 3 or 4, 5).”8(p S303)
The patient was a good candidate for phase 2 (Tab. 1) of our mobility program because she had relatively stable hemodynamics, was able to maintain adequate respiratory status with ventilator support, could follow commands,20,28,30 and was dependent on assistance for standing due to severe weakness. The patient consented to participate in physical therapy interventions, and the Health Insurance, Portability, and Accountability Act (HIPAA) requirements were met.
Intervention
Two principles were central to the design of the exercise interventions. Based on the overload principle, the exercises chosen challenged the physical capacity of the patient by working her near the limits of her abilities, to achieve desired adaptations (eg, increased strength, greater aerobic capacity).31 In addition, the principle of “specific adaptation to imposed demands” was important when selecting exercises and activities. According to that principle, the response to exercise will be adaptations that are uniquely linked to the types of demands imposed. Therefore, an exercise program should be designed to closely replicate the demands and physical functions that are needed after rehabilitation, so that the patient achieves the optimal response from the exercises.31 Based on the objective of achieving specific adaptation to imposed demands, the initial intervention selected was the inclined leg press device, which simulated the patient's goal of performing sit-to-stand activities. The inclined leg press allowed the physical therapist to make subtle adjustments to the resistance in accordance with the patient's performance.
Application of the overload principle must be subsumed to safety. Therefore, this patient's progression of therapeutic exercise on the leg press and mobility training was accompanied by continuous measurement of cardiovascular and respiratory responses, and the amount and rate of the physical demands were graded and continuously adjusted to optimize the benefits from interventions while minimizing risk from exceeding her capacity.22 Our criteria for safe intervention responses were: heart rate between 40 and 130 bpm, respiration rate between 5 and 40 breaths per minute, oxygen saturation >88%, mean arterial blood pressure between 65 and 110 mm Hg, and systolic blood pressure <200 mm Hg, and no activity upon the development of an arrhythmia, angina, or complaint of distress or fatigue.32,33
In addition to continuously monitoring vital signs, the Borg rating of perceived exertion (RPE) scale was applied to assess the patient's self-reported feeling of exertion and fatigue to determine exercise intensity. The scale ranges from 6 to 20, where 6 means “no exertion at all” and 20 means “maximal exertion.”34 Our goal was to keep the RPE between 10 and 15 during 3 sets of 10 to 15 repetitions on the mobile leg press.
During the initial treatment session, the patient was able to independently perform 3 sets of 10 shallow squats (movement from 0° to 60° of knee flexion) at a 15-degree incline, creating resistance equivalent to 35% of her body weight, during a 20-minute session. The manual muscle test results suggested that performance should have been poorer. We have observed a similar response in other patients and attribute it to the functional (ie, practical) demands of the squat in contrast to the nonfunctional demands of manual muscle testing. The patient's heart rate, oxygen saturation, respiratory rate, and blood pressure remained within acceptable ranges during the exercises, and her reported RPE was 13, indicating that her level of exertion was “somewhat hard but feels OK to continue.”34
After performing the leg press exercise for leg strengthening, the patient was transferred back to bed and assisted to the sitting position to work on trunk stability. She was able to sit upright with maximal assistance for 3 minutes. This regimen continued for the next 10 days, and the patient progressed to performing 3 sets of 10 inclined squats with 45% of her body weight and achieved the capacity to sit with moderate assistance for 10 minutes at the edge of the bed. The interventions were performed with the patient demonstrating that performance was within her capacity (vital signs in acceptable range, RPE 10–15).
The patient experienced a medical setback on day 32 from onset of illness (day 11 at LTACH). A radiograph revealed a pleural effusion in the right lung that warranted an emergent thoracentesis. After the procedure, the patient's hemodynamic status became unstable, which necessitated transfer back to the STACH. She spent an additional 21 days at the STACH ICU until medically stable. A physical therapist evaluated her on day 47 (15 days into her second stay in the STACH), and the therapist's recommendation was for nursing personnel to perform passive ROM every shift. On day 56 from initial onset (24 days into her second stay in the STACH), the patient was transferred from the STACH back to the LTACH setting for continued management of her condition.
Second LTACH Assessment
Our second examination in the LTACH was on day 56. The patient was alert, could follow simple commands, and was mechanically ventilated on continuous positive air pressure mode with an Fio2 of 0.45. Manual muscle testing revealed the patient had trace (1/5) shoulder abduction, poor (2/5) strength of elbow flexion, wrist extension, hip flexion, and knee extension, and zero (0/5) strength for dorsiflexion bilaterally, yielding an MRC sum score of 18/60 (video 0:04). She required maximal assistance from 2 therapists to sit up at the edge of bed and was able to tolerate sitting for 2 minutes and was limited by fatigue.
The following day, we restarted phase 2 of the mobility program, which consisted of inclined squats on the mobile leg press and assisted sitting balance activities. The patient performed 3 sets of 10 inclined squats independently against 35% body weight and performed static standing for 12 minutes with 50% body weight, which appeared to facilitate isometric muscle contractions of the antigravity muscle groups (Fig. 1; video 1:11). Active-assisted arm exercises (shoulder flexion and elbow flexion) also were performed during static standing for upper body strengthening. After the leg press exercise, the patient sat upright at the edge of the bed for 4 minutes with maximal assistance and performed assisted exercises. Exercises during sitting consisted of active-assisted trunk flexion extension, lateral bending, and rotation, as well as active-assisted ROM exercises of the upper and lower extremities. These exercises were selected to promote strengthening of the muscles of the trunk and extremities. The patient appeared to work vigorously and within her capacity (vital signs in acceptable range, successful performance of exercises with RPE 10–15) during the session.
The patient performing leg presses with 35% body weight for partial weight-bearing, antigravity strength training on day 57.
This regimen continued daily with adjustments to increase the resistance or number of repetitions of the exercise to work the patient toward the limits of her abilities, which was determined by observing her performance and level of perceived exertion. The patient actively participated in the progression of exercise by voicing her readiness to raise the leg press incline when her RPE was too low at a given incline. She stated that she enjoyed the leg press exercises and that the workout reminded her of a Pilates class at the gym.
Four days later (day 61), the patient was able to perform 4 sets of 12 inclined squats against 55% of her body weight on the leg press, stand on the inclined leg press with 70% body weight for 15 minutes, and sit independently with bilateral arm support for 5 minutes. The treatment session duration progressed from 35 to 45 minutes. At this time, the patient stated that her legs felt stronger and that she was ready to attempt standing.
Based on her improving performance with the inclined squats on day 62, assisted standing was assessed and the patient was able to transition from sitting to standing with moderate assistance. Once fully upright, she was capable of supporting the majority of her body weight through the lower extremities, which met the criteria to initiate phase 3 of the mobility program using the hydraulic-assist platform walker for standing exercises. She was able to stand for 30 seconds with moderate assistance using the hydraulic-assist platform walker. After the standing session, the patient was transferred to a wheelchair, which required maximal assistance, and she sat up in the wheelchair for 25 minutes before she complained of fatigue and pain.
This regimen of progressive standing with the hydraulic-assist platform walker followed by supported sitting in a wheelchair continued until day 69 when the patient progressed to ambulating 5 ft with the hydraulic-assist platform walker and moderate assistance (Fig. 2; video 1:52). At this time, her capacity for activity had progressed such that she was sitting up in the wheelchair for 1 hour and able to propel the wheelchair 15 ft with minimal assistance. She also had been weaned from the ventilator to a tracheal collar at 28% Fio2 without desaturation during activity. On day 70, the patient walked 12 ft using the hydraulic platform walker, which met our criteria to progress to phase 4 activities.
The patient using a hydraulic-assist platform walker for upright standing on day 69.
Phase 4 activities consisted of progressive ambulation, balance, and endurance training. On day 77, the patient ambulated 55 ft, with minimal assistance from the physical therapists, using the hydraulic-assist platform walker (video 2:27). She also was weaned off all supplemental oxygen at that time, decannulated, and participated in exercises without desaturation. The next progression, based on the improvement of her upper-extremity strength to greater than 3/5 and her improved performance with the hydraulic-assist platform walker, was advancement to balance training in the parallel bars, which required acceptance of weight bearing through her hands (instead of the forearms). On day 78, the patient ambulated 8 ft in the parallel bars and required moderate assistance for support in an the upright position to avert falls. She displayed occasional knee buckling during this session and voiced frustration about how walking in the parallel bars was significantly more difficult than the hydraulic-assist platform walker. We interpreted this as an appropriate response to the intervention, because it indicated that we were challenging her very near the limits of her abilities while her physical responses (heart rate, respiratory rate, oxygen saturation, and blood pressure) remained within acceptable limits (Fig. 3; video 2:52).
The patient using the parallel bars for gait re-education and balance training on day 78.
On day 79, the patient was able to use a rolling walker, which required weight bearing through the hands and provided less stability than the parallel bars, and she ambulated 15 ft with moderate assistance (video 4:11). Knee buckling during walking indicated that she had insufficient strength in her legs and trunk to perform this activity without assistance, and moderate assistance was required to allow her to participate in the training without falling. During this phase, the goals included increasing her aerobic capacity and decreasing her reliance on assistance for transferring and walking. Progress toward these goals was achieved with gait training by using the rolling walker to ambulate for greater distances for aerobic exercise. Gait training and transfer training were provided with physical support that was reduced over time so that these activities provided the patient with demands for increasing support from her legs while specifically training her for the functional tasks of transferring and walking.
Adjunctive activities during this time consisted of the leg cycle ergometer, which provided graded advancement of aerobic demands; propelling the wheelchair backward with her legs to build knee extensor strength; and use of the Wii boxing game (Nintendo of America Inc, Redmond, Washington) to improve upper body strength, endurance, and postural control (video 3:48).
Outcome
On the day of discharge to an inpatient rehabilitation facility (day 89), the patient was independent with bed mobility skills and was able to perform a stand-pivot transfer using a walker with supervision. She was able to ambulate 150 ft using a rolling walker with supervision (Fig. 4; video 5:04). She was breathing on room air and was able to perform the leg cycle ergometer for 8 minutes. Vital signs and oxygen saturation levels stayed within acceptable ranges. The MRC sum score had increased from 18 at admission to 52 at discharge (Tab. 2). A time line of significant events is presented in Table 2.
At discharge on day 89, the patient walked 150 ft using a rolling walker under supervision.
Time Line of Significant Eventsa
Discussion
The primary concern when designing an exercise program for a patient with critical illness and severe weakness is safety. The graded mobility program using the mobile leg press for partial weight-bearing exercise and the platform walker proved to be safe and feasible for this patient. In addition, exercise with these devices resulted in the provision of less physical assistance from the therapists.
Utilizing the mobile leg press in the early stage of rehabilitation for this patient, we were able to precisely adjust the level of resistance to her physical ability. Reducing the exercise intensity early in the program, compared with manually standing the patient with therapist assistance, allowed the patient to participate in longer treatment sessions, typically 20 to 30 minutes, while performing leg presses or holding a position for lower-extremity isometric strengthening. We intentionally provided exercises for a 20- to 30-minute duration to achieve cardiopulmonary benefits, because these benefits are associated with the duration of activity. As the patient experienced increases in the level of exercise intensity, she appeared to possess a greater sense of motivation and accomplishment that was probably due to increasing self-efficacy.
Without the leg press device, the therapists would have had to manually lift the patient until she could support full body weight, which is uncomfortable for the patient and fosters dependency with an accompanying reduction in self-efficacy. In addition, manually standing the patient would have certainly been rated by her at a level near 20 or “maximal exertion” on the RPE scale because it was beyond her physical ability. We propose that the most important benefit from the leg press exercise was that it provided the patient with rigorous, graded resistance to achieve controlled overload, which increased her strength. The specificity of training achieved by applying closed-chain, antigravity activities transferred to rapid improvements in her ability to perform relevant functional tasks, including transfers and ambulation.
The justification for the use of the hydraulic-assist platform walker was similar to that for the inclined leg press in that it reduced the intensity of the work of ambulation to a level at which the patient could succeed. In contrast, using a rolling walker with moderate assistance from the physical therapists would have increased the patient's reliance on the physical therapists and provided greater physical demands with rapid fatigue. By allowing the hydraulic motors to assist the patient during the sit-to-stand movement, and supporting her weight through her forearms, she was capable of participating in standing and walking earlier in her course of rehabilitation and for longer periods. We propose that this was a valuable component of the patient's program and accelerated her development of the capacity to ambulate greater distances. For example, on day 78, the patient was capable of walking 55 ft with the hydraulic-assist platform walker and minimal assistance, yet she required moderate assistance in the parallel bars and could only ambulate 8 ft. This ability to walk with less assistance and for longer distances helped improve her self-efficacy and her aerobic capacity.
The program we designed to increase functioning included inclined squats, balance training in sitting, transfer training, and gait training. The exercise intensity of these interventions was titrated throughout the program using vital sign responses (changes in heart rate, blood pressure, respiratory rate, and oxygen saturation) and RPE. The physical therapist adjusted the intensity, duration, and frequency of the exercise interventions to provide graded challenges to the patient's cardiopulmonary system. The purpose was to encourage adaptations of the cardiopulmonary and muscular systems so that the patient could progress to engaging in greater levels of activity and tolerate greater physical demands. Her initial intolerance to continuous activity resulted in short-duration sessions. To compensate for that, the physical therapist chose to perform shorter, more frequent sessions of activity to achieve the desired response of improving aerobic capacity.35,36 Exercise sessions implemented later in this program deliberately advanced to longer duration (eg, 45 minutes) to offer sufficient physical demands to achieve the overload necessary for the adaptations accompanying increasing endurance.
In addition, it is important to note that the adjunctive activities were performed after the gait training so that the patient was not fatigued prior to the functional task of walking. Performing an adjunctive intervention, such as the leg cycle ergometer, prior to gait training would likely have reduced the patient's gait distance, which, in turn, could have reduced the patient's self-confidence by not progressing that day. Progressing in walking distance each day was a significant motivator for this patient and often was followed by the therapists and family applauding her achievement.
This patient received physical therapy services in 2 ICUs. There were 2 stays in a STACH-based ICU (days 2–21 and 33–55), during which physical therapy was consulted and the determination was made to have passive services provided within nursing care. There were 2 stays in a LTACH (days 21–32 and 56–89), during which a physical therapist–led program of interventions was provided. Analyses of physical therapist practice in hospitals have revealed variation in practices across institutions37 and among ICUs.38,39 Our interpretation was that the differences in the physical therapy services this patient received during the ICU stays were related to the cultures within those settings rather than due to her health status.40,41
This case report demonstrates our program of increasing mobility and physical demands utilizing novel therapeutic devices was an effective patient-centered approach. It allowed this patient to gradually increase her activity tolerance with more control and independence. Future research is needed to examine whether partial weight-bearing antigravity exercise and early standing and walking activities with a hydraulic-assisted platform walker lead to improved recovery of strength and functioning compared with traditional rehabilitation approaches.
Appendix.
Assistance Levelsa
a Reprinted with permission from: Guccione AA, Scalzitti DA. Examination of functional status and activity level. In: O'Sullivan SB, Schmitz TJ, eds. Physical Rehabilitation. 5th ed. Philadelphia, PA: FA Davis Co; 2007;373–400.
Footnotes
Dr Trees provided concept/idea/project design and data collection. All authors provided writing and consultation (including review of manuscript before submission). Mr Hockett provided data analysis, facilities/equipment, and clerical support. The authors thank “Phyllis” for her willingness to participate in this case report and to share her ICU recovery so that other ICU survivors may benefit.
- Received November 14, 2011.
- Accepted May 2, 2012.
- © 2013 American Physical Therapy Association
References
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