Research in Focus: Early Rehabilitation Reduces the Likelihood of Developing Intensive Care Unit-Acquired Weakness

  •   June 30, 2020
  •  Leanne Loranger, PT

Full Citation: Anekwe DE, Biswas S, Bussieres A, Spahija J. Early Rehabilitation Reduces the Likelihood of Developing Intensive Care Unit-Acquired Weakness: A Systematic Review and Meta-analysis. Physiotherapy 2020; 107:1-10

Background

Critical illness is known to be associated with ICU-Acquired Weakness (ICUAW) one component of Post-ICU Syndrome (PICS). ICUAW is a “clinically detected weakness in critically ill patients in whom there is no plausible etiology other than critical illness.”1 PICS is characterized by a combination of mental health, cognitive and physical impairments effecting survivors of critical illness.2 (Mel Major – COVID Webinar) It has been estimated that 40% of critically ill adult patients experience ICUAW.3  ICUAW and PICS lead to significant long-term impacts on function and quality of life for individuals surviving critical illness. Given the high prevalence of ICUAW, prevention is key.

This systematic review and meta-analysis updated prior reviews and summarized what is currently known regarding the extent to which early rehabilitation in the form of early mobility (EM) and neuromuscular stimulation (NMES) reduce the incidence of ICUAW as compared to usual care.

Methods

  • Systematic review and meta-analysis
  • Databases searched – MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and Physiotherapy Evidence Database
  • Publication Dates – database inception to May 1, 2017
  • Inclusion Criteria:
    • RCT
    • Conducted in an ICU
    • Adult participants
    • Evaluated the effect of EM or NMES
    • Reported incidence of ICUAW or used the Medical Research Council Scale to assess muscle strength
  • Exclusion Criteria:
    • Studies that evaluated interventions for patients already diagnosed with ICUAW
  • Included studies were assessed using the Cochrane Risk of Bias Tool
  • Primary Outcome – incidence of ICUAW at any time after initiation of intervention
  • Secondary Outcomes:
    • Length of time on mechanical ventilation
    • Discharge location
    • ICU and hospital LOS
    • Acute mortality
  • Intention to treat analysis
  • 9 articles met inclusion criteria after screening for eligibility and full-text review
    • Total of 841 patients (419 in intervention group, 422 in control group)

Findings

  • Individuals receiving early rehabilitation had lower odds of developing ICUAW.
  • Further, “the impact of rehabilitation on the odds of developing ICUAW was more profound in a subgroup of studies in which patients had longer ICU LOS.”
  • Odds of developing ICUAW were lower where early rehabilitation was initiated within 72 hours of ICU admission.
  • There was no difference in the odds of acute mortality between intervention and control groups.
  • Meta-analysis of discharge location showed increased odds of discharge home in favor of the early rehabilitation group.
  • Three studies were assessed as having high risk of bias, one had unclear risk, and five showed low risk of bias.

Limitations

  • Search strategy identified only RCTs that investigated the primary outcome of interest, so conclusions related to secondary outcomes may be limited by exclusion of relevant studies.
  • Several included studies (6/9) included EM as the part of the control group “routine care;” however, the authors report that the impact of this was mitigated statistically by using odds ratios. In addition, this may artificially reduce the reported difference in odds of developing ICUAW between intervention and control groups.

Relevance to physiotherapy practice in Alberta

The COVID-19 pandemic has increased awareness of the significant long-term impacts of ICU admission on function and quality of life for individuals surviving critical illness.

Physiotherapists have a role to play in the provision of early rehabilitation of patients admitted to the ICU, regardless of the underlying cause of admission, to mitigate these effects and improve patient outcomes.

Further, given that a patient’s future ICU LOS is unknown at the time of admission, and the impact of early rehabilitation on ICUAW is more profound for patients with longer ICU LOS and when intervention is initiated within 72-hours of ICU admission, physiotherapists should intervene as early as safely possible, with all patients admitted to the ICU. The costs related to providing this intervention may be outweighed by the long-term net savings arising from prevention of ICUAW and improved quality of life for ICU survivors.

Disclaimer: The purpose of this summary is to highlight recently published research findings that are not openly accessible. Every effort is made to ensure accuracy and clarity of the summary. Readers are encouraged to review the published article in full for further information.


  1. Anekwe DE, Biswas S, Bussieres A, Spahija J. Early Rehabilitation Reduces the Likelihood of Developing Intensive Care Unit-Acquired Weakness: A Systematic Review and Meta-analysis. Physiotherapy 2020; 107:1-10
  2. Major, M. Recovery After (COVID19) Critical Illness. From: The Continuum of Care for COVID-19 Patients. Lecture presented at; 2020 Physiotherapy Alberta Online Webinar. Available at https://www.physiotherapyalberta.ca/xchange/continuing_professional_development/elearning_center/the_continuum_of_care_for_patients_with_covid_19/?search_term=covid. Accessed June 18, 2020.
  3. Inoue S, Hatakeyama J, Kondo Y, Hifumi T, Sakuramoto H, Kawasaki T, Taito S, Nakamura K, Unoki T, Kawai Y, Kenmotsu Y, Saito M, Yamakawa K, Nishida O. Post-Intensive Care Syndrome: Its Pathophysiology, Prevention and Future Directions. Acute Medicine & Surgery 2019; 6(3):233-246. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6603316/ Accessed June 19, 2020.