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CardiopulmonaryPhysical TherapyJournal

Official Journal of the Cardiovascular & Pul mo nary Sec tionAmerican Physical Therapy As so ci a tion

Volume 23 ❖ Number 1 ❖ March 2012

SPECIAL ISSUE: PHySICAL THERAPy IN CRITICAL CARE

Cardiopulmonary Physical Therapy JournalVol 23 ❖ No 1 ❖ March 2012 3

Table of Contents

4 Guest Editorial: Physical Therapy in Critical Care

Susan Scherer

5 Early Mobilization in the Intensive Care Unit: A Systematic Review

Joseph Adler, Daniel Malone

14 Respiratory and Hemodynamic Responses to Mobilization of Critically Ill Obese Patients

Arzu Genc, Seher Ozyurek, Ugur Koca, Ali Gunerli

19 Physiotherapy in Critical Care in Australia Susan Berney, Kimberley Haines, Linda Denehy

26 What are the Barriers to Mobilizing Intensive Care Patients?

I Anne Leditschke, Margot Green, Joelie Irvine, Bernie Bissett, Imogen A Mitchell

30 Physical Therapy Management of a Patient on Portable Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplation: A Case Report

John D. Lowman, Tamara K, Kirk, Diane E. Clark

36 Using Simulation and Patient Role Play to Teach Electrocardiographic Rhythms to Physical Therapy Students

Nancy Smith, Sharon Prybylo, Teresa Conner-Kerr

Editor-in-ChiefAnne K. Swisher, PT, PhD, CCSWest Virginia University

Features EditorSusan Scherer, PT, PhDRegis University

Consulting EditorGerald R. Hobbs, PhDWest Virginia University

Associate EditorsSean Collins, PT, ScDUniversity of Massachusetts at Lowell

W. Darlene Reid BMR (PT), PhDUniversity of British Columbia

Editorial BoardJennifer Alison, PT, PhDUniversity of Sydney

Lawrence Cahalin, MA, PT, CCSUniversity of Miami

Sandra Cassady, PT, PhD, FAACVPRSt. Ambrose University

Joseph Norman, PT, PhD, CCSUniversity of Nebraska

Jane Schneiderman, CEP MS (ExSci)Hospital for Sick Children, Toronto, Ont

Advertising & SubscriptionsCopyright 2012 (ISSN 1541-7891) by the Cardiovascular and Pulmonary Sec tion, APTA. Opinions expressed by the authors are their own and do not necessarily reflect the views of the Car dio vas cu lar and Pul mo nary Section. The Editor reserves the right to edit manu scripts as necessary for publication. The Cardio pulmonary Physical Therapy Journal is indexed by the National Library of Medicine (PubMed Central), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EBSCO Research Databases, and the Thomson Gale Databases (Academic One File).

All advertisements which appear in or accompany the Cardio-pulmonary Physical Therapy Journal are accepted on the basis of conformation to ethical physical therapy standards, but ac cep tance does not imply en dorse ment by the Car dio vas-cu lar and Pulmonary Section.

Subscription Rates: Advertising Rates:Nonmembers - $50.00 Full page ad - $500.00Foreign Subscriptions Half page ad - $300.00 Canada & Europe - $65.00 Quarter page ad - $200.00 Asia - $80.00Institutions - $70.00 Advertising:Foreign Institutions Kristen Mullins Canada & Europe - $85.00 West Virginia University Asia - $100.00 Morgantown, WV Back Issues - $10.00 each [email protected] (when available) 304-293-3610

Cardiopulmonary Physical Therapy Jour nalOfficial Journal of the Cardiovascular & Pulmonary Section

American Physical Therapy Association

Publication Title: Cardiopulmonary Physical Therapy JournalStatement of Frequency: Quarterly: March, June, September, & De cem berAuthorized organization’s name and address: Orthopaedic Section, APTA, Inc. For the Cardiopulmonary Section 2920 East Avenue South, Suite 200 La Crosse, WI 54601-7202

Cardiopulmonary Physical Therapy Journal Vol 23 ❖ No 1 ❖ March 20124

Editorial

The role of physical therapists in critical care has been evolving. Of interest to this section, traditional PT care in the ICU focused on interventions for respiratory conditions, using techniques such as percussion, manual hyperinfla-tion, suctioning, and bed exercises. As our knowledge of the importance of early mobilization has evolved, as evi-denced by changes in how quickly patients are out of bed following cardiac surgery, the interventions in physical therapy have changed. The physiologic rationale for early mobilization has been discussed since the early 1990s in papers written in part by leaders in cardiovascular and pul-monary physical therapy.1 What has been lacking is strong evidence of the benefits of early mobilization in critically ill patients. In the past few years, the number of poster and platform sessions at the Combined Sections Meetings focused on physical therapy in critically ill patients has in-creased. Similarly, the number of published articles on this topic is growing.

The topic for this special issue developed in response to these trends. Our call for papers resulted in a variety of manuscripts. We have a systematic review of mobilization in the ICU, which focuses on both safety and effectiveness outcomes. There is good evidence to support the effective-ness of early mobilization, even in patients on mechanical ventilation. Several interesting case examples are included that will be very useful in helping clinicians determine the types of interventions and outcomes most relevant to treat-ing patients in ICU environments. One paper also addresses what can be done in the academic environment to prepare students for work in these complex practice environments. And, we benefit from the expertise of our colleagues in oth-er countries; in this edition, we have examples from Turkey and Australia as well as the United States.

The articles chosen for this issue illustrate several treat-ment trends that will help advance the work of PT in the critical care environment. One of our articles discusses the barriers to treatment of patients in the ICU. This shows us that some barriers, such as timing of medication administra-tion, could be easily addressed, but will require the physical therapist to be committed to active mobilization of patients and demonstrate ability to communicate effectively with other members of the ICU team. Overall, there are relatively few adverse effects of early mobilization, particularly when therapists are observing the physiologic response of patients by monitoring vital signs during treatment sessions. A num-ber of articles discussed in the systematic review provide guidelines for discontinuing treatment based on vital sign responses. This reminds us that we need increasing focus on one of the key tenets of cardiopulmonary physical therapy practice; that we are treating the patient’s physiologic deficits in conjunction with movement and functional abnormalities.

Guest Editorial: Physical Therapy in Critical Care

There is much work to be done in advancing the prac-tice of PT in these critical care environments. What an ex-citing time of practice to be able to shape the interventions and influence better health outcomes for our patients!

REFERENCE1. Ross J, Dean E. Integrating physiological principles into

the comprehensive management of cardiopulmonary dysfunction. Phys Ther. 1989;69(4):255-259.

Susan Scherer, PT, PhDAssociate Editor


Early Mobilization in the Intensive Care Unit:A Systematic Review

Joseph Adler, PT, DPT, CCS1

Daniel Malone, PhD, MPT, CCS2

1Good Shepherd Penn Partners at The Hospital of the University of Pennsylvania, Philadelphia, PA2Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Denver, CO

Address correspondences to: Joe Adler, PT, DPT, CCS, Good Shepherd Penn Partner’s at the Hospital of the University of Pennsylvania, Department of Occupa-tional and Physical Therapy, 1st Floor White Build-ing, 3400 Spruce Street, Philadelphia, PA 19104 ([email protected]).

ABSTRACTPurpose: The purpose of this review is to evaluate the litera-ture related to mobilization of the critically ill patient with an emphasis on functional outcomes and patient safety. Methods: We searched the electronic databases of PubMed, CINAHL, Medline (Ovid), and The Cochrane Library for a period spanning 2000-2011. Articles used in this review in-cluded randomized and nonrandomized clinical trials, pro-spective and retrospective analyses, and case series in peer-reviewed journals. Sackett’s Levels of Evidence were used to classify the current literature to evaluate the strength of the outcomes reported. Results: Fifteen studies met inclu-sion criteria and were reviewed. According to Sackett’s Levels of Evidence, 9 studies were level 4 evidence, one study was level 3, 4 studies were level 2, and one study was level one evidence. Ten studies pertained to patient safety/feasibility and 10 studies pertained to functional outcomes with 5 fitting into both categories. Conclusion: A search of the scientific literature revealed a limited number of studies that examined the mobilization of critically ill patients in the intensive care unit. However, literature that does exist supports early mobilization and physical therapy as a safe and effective intervention that can have a significant impact on functional outcomes.

Key Words: mobilization, exercise, intensive care unit, crit-ical illness, physical therapy

INTRODUCTIONThe early mobilization of patients in the intensive care

unit (ICU) has received considerable attention in clini-cal and scientific literature over the past several years.1-3 A wide range of published reports has attempted to study the effects of mobilization and physical therapy on mul-tiple factors including patient safety, ambulation capacity,

muscle strength, functional outcomes such as activities of daily living, duration of mechanical ventilation, ICU length of stay, hospital length of stay, and mortality.

There are inherent complications to mobilizing critical-ly ill patients that appear straightforward but are not well established. These apparent complications include, but are not limited to: tenuous hemodynamic status, severe weak-ness, multiple central catheters and life supporting moni-tors, artificial airways and operational factors such as vari-able rehabilitation work practices.4-7

Studies have demonstrated that survivors of critical ill-ness have impaired exercise capacity and persistent weak-ness, suboptimal quality of life, enduring neuropsychologi-cal impairments and high costs of health care utilization.8-12 It has been hypothesized that ICU-based interventions may play a role in reducing these ongoing physical and neu-ropsychological impairments in ICU survivors in both the short- and long-term, highlighting the importance of study-ing this population.12

When patients require admission or readmission to the ICU, a period of enforced bed rest generally ensues. Despite knowledge of the deleterious effects of bed rest on multiple body systems,13-16 the ICU is a complicated and difficult environment in which to mobilize the critically ill.1,17 Mul-tiple life-sustaining catheters and monitors, sedative medica-tion used to calm agitation or reduce energy expenditure, impaired levels of alertness from medications, sleep distur-bances, electrolyte imbalances, and tenuous hemodynamic status all are contributing factors that limit mobilization.

As critical care medicine improves and overall mor-tality decreases, survivors of ICU admissions are realizing greater morbidity. Severe weakness, deficits in self-care and ambulation, poor quality of life, hospital readmission, and death have all been reported in patients up to 5 years after discharge from the ICU.12,18

Mobilizing patients in the intensive care environment is not without risk. Catheters and supportive equipment at-tached to patients can become dislodged and cause injury. Insertion and reinsertion of catheters can increase infection risk and cause unwanted stress and pain for patients and families already stressed by the medical acuity of the ICU. Critically ill patients with physiological derangements can have adverse hemodynamic responses to activity. Patients with limited aerobic capacity may respond to exertional


stress with exaggerated heart rate and blood pressure re-sponses or conversely may not have enough physiologic reserve to meet even the seemingly simple task of sitting on the edge of the bed.

Although the frequency of published reports related to mobilizing critically ill patients is increasing, the number of controlled, randomized trials is few. The purpose of this review was to examine the literature and characterize the clinical benefits of mobilizing critically ill patients found predominantly in the ICU, specifically related to safety and functional outcomes.

METHODSLiterature Search

The electronic databases of PubMed, CINAHL/Nursing, Medline (Ovid) and the Cochrane Library were searched as noted in Figure 1. The key search terms, “mobilization,” “exercise,” and “physical therapy” were combined with “intensive care unit” and “critical illness.” Reference lists of review articles and original publications were manually re-viewed supplementing the electronic search to ensure that the database searches were comprehensive.

Study Selection Criteria Articles included in this review were: prospective ran-

domized trials, prospective cohort studies, retrospective analyses, and case series. We further limited our inclusion to articles that focused on adults that were published in English between January 1, 2000 and June 1, 2011 to cap-ture the most recently published work. Studies were evalu-ated to determine fit to the inclusion criteria by review of

the title, and the list of potential articles was further sorted by reviewing abstracts by the primary author (JA). Studies were excluded if they were review articles, only studied nonmobility interventions, and/or described programs or protocols designed to promote early mobilization. If rel-evancy was questioned, both authors then collaborated on the final decision for inclusion.

Levels of EvidenceSackett’s Levels of Evidence were used to rate the

strength of the research19 process where research was ranked from strongest to weakest using a 5 point grading system as outlined in Table 1. The authors (DM and JA) col-laborated equally on scoring.

Table 1. Sackett’s Levels of Evidence1A Systematic Review of Randomized Controlled Trials (RCTs)

1B RCTs with Narrow Confidence Interval

1C All or None Case Series

2A Systematic Review Cohort Studies

2B Cohort Study/Low Quality RCT

2C Outcomes Research

3A Systematic Review of Case-Controlled Studies

3B Case-controlled Study

4 Case Series, Poor Cohort Case Controlled

5 Expert Opinion

Adapted from Levels of Evidence. Oxford Centre for Evivdence-based Medicine - Levels of Evidence (March 2009) Website. Available at www.cebm.net. Accessed September 26, 2011.

Figure 1. Search algorithm.

RESULTSFifteen studies were included in

this review and submitted to analysis. Many outcomes were reported in the mobilization of critically ill patients and included a wide range of data. The studies were categorized into two groups based on the outcome addressed: safety and functional out-comes. Functional outcomes were further subdivided into one of 3 areas: muscle strength; quality of life/patient symptoms, and mobility. Some stud-ies overlapped multiple categories. Of the studies reviewed, 4 reported on muscle strength, two on quality of life, and 13 on functional mobility.

Studies included both prospective and retrospective design while ran-domization occurred in just 3 stud-ies.20-22 The randomization in Chiang et al’s study22 occurred in a postinten-sive care environment. Ten studies ex-amined cohort populations or samples of convenience. Eleven of those were prospective.4,20-29 Four studies were


Table 2. Safety and ICU MobilizationStudy Study Design

(N= subjects)Sackett’s Levels of Evidence

Physical Therapy Interventions

Safety profile Other notable findings

Stiller K. 200427 Prospective

One-group pretest-posttest design

N= 160 total patients with 31 receiving mobilization

4 Functional mobility• Supine-to-sit• Sittingedgeofbed• Standing• Transfers• Ambulation

69 mobilization sessions with 31 patients (MV = 7 patients (23%)):

3 events (4%) during PT treatments (2 patients on MV) • desaturation(≤88%)responsiveto

increased FIO2

Overall, no serious adverse medical consequences

• Studyhighlightsthephysiologicresponses(HR, BP, SpO2) and patient safety associated with mobilization

• Paper“reintroduces”analgorithmforsafepatient handling pertaining to the acute care/ ICU settings

• Only31of160ofpatients(19%)weremobilized following the screening process

Zafiropoulos B. 200429

Prospective


N=17

4 Patients participated in progressive mobilization from supine> sitting> standing> marching x 1 minute for each activity

• Minuteventilationincreaseddue to increases in tidal volume & respiratory rate with standing with no additional increase with marching; the breathing pattern demonstrated greater upper chest versus abdominal excursion

• ABGvalueswerenormal• HR/BP/MAPincreasedwith

mobilization from supine> sitting

Overall, no adverse medical consequences

• Studyemphasizedthehemodynamicandrespiratory responses in patients who were s/p abdominal surgery◊ Included measurements of chest

wall and abdominal movements to characterize the breathing pattern

• Nohemodynamicorrespiratorycompromise

• Alteredbreathingpatternfavoredupperchest breathing/ ventilation

• Painwasnotmonitored• Nocontrolgroupforcomparison

Bailey P. 200723 Prospective


N=103 patients

4 Twice daily PT/ activity sessionsFunctional Mobility• Supine-to-sit• Sittingedgeofbed• Standing• Transfers• Ambulation

FIO2 was increase 0.2 prior to sessions

1449 PT/ activity sessions:

14 events (<1%) occurred during PT sessions:• fallstoknees(x5)• desaturation<80%(x3)• SBP<90mm(x4)• SBP>200mmHg(x1)• Nasogastrictuberemoval(x1)Overall, no serious adverse medical consequences

• Studyprovidessystemsreviewcriteria(neurologic/ circulatory/ respiratory) used to screen patients prior to mobilization

• Oftheapproximate1500activitiesperformed:◊ Sit at edge of bed (16%)◊ OOB (31%)◊ Ambulate (53%)

• Age&comorbiditiesdidnotinfluenceambulatory status

Morris PE. 200825 Prospective

Cohort study

(N=330; 165 intervention/ protocol; 165 “usual” care”)

2B Mobilization program implemented 7 days/ week by “mobility team” consisting of: PTCritical care RNNursing assistant

• 116of135patients(80%)ofprotocol patients received PT during hospital stay for approx. 638 total PT sessions

• TherapysessionsnotinitiatedifBP/ HR outside of listed inclusion criteria (£ 1.4% of total sessions)


• Protocolformobilization(activityalgorithm) and criteria for limiting therapy sessions are well defined

• Mobilitysessionsprimarilyendeddueto patient c/o fatigue without significant change in vital signs

Burtin C. 200921 Prospective

RCT

(N = 90 enrolled; 67 completed) (36 control; 31 treatment group)

2B 5 days/ weekBoth groups received:Upper extremity ther. ex.Lower extremity ther ex. Functional training. Treatment group: Additional cycling session x 20 minutes total, daily

425 total exercise sessions• 16sessions(<4%)terminateddueto

desaturation <90% or HTN; • 3subjectswithdrawn:

◊ Achilles tendon rupture (x1)◊ cardiorespiratory instability

(x2)

Achilles tendon rupture could be considered a serious adverse event• injurymostlikelyduetotheadditionof

cycling as a treatment modality• cardio-respiratoryinstabilitynotwell

defined in paper.

Schweickert WD. 200920

Prospective

RCT

(N=104; all patients completed study)

1B 7 days/ weekTreatment group: Progressive UE/ LE ther ex.; Trunk control/ balance activities Functional training including ADL’s

498 PT/ OT sessions:• 1desaturation<80%• 1radialarterylineremoved• PT/OTwasdiscontinuedduring19

sessions (4%) for perceived patient-ventilator asynchrony

Overall, no adverse medical consequences

• Protocolformobilizationandcriteriaforlimiting therapy sessions are well defined

• StudysupportsthatearlyPT/OTissafeand the primary event limiting patient participation in PT/OT was patient-ventilator asynchrony

Pohlman MC. 201032

Retrospective

Descriptive study/ case series using data from prior study (see Schweickert above)

N= 49 patients

4 As noted above In patients receiving MV, the primary reasons for missed therapy session• MVasynchrony(<4%)• MAP<65mmHg(<1%)• Vasoactivemedication(<1%)• ActiveGIB(<1%)

PT/ OT sessions were terminated due to• Desaturation>5%(6%)• HR&MVasynchrony(4%)• Agitation/discomfort(2%)• Device/lineremoval(<1%)Overall, no adverse medical consequences

• EarlyPT/OTisfeasible&safewithin24-48 hours of ICU admission/ MV

• PT/OToccurredon87%ofeligibledays(n=498 of 570); # of missed session similar between MV and extubated patients

• Patientsperformedmoreaggressivemobilization as they progressed from MV to extubation

• PT/OTsessionsproceededeventhoughpatients had central venous access/ HD catheters; arterial lines; ETT/ tracheostomy tubes

• Followingextubation,PT/OTheldprimarily due to patient refusal (c/o fatigue)

Zanni JM. 20104

Prospective Pilot Project


(N= 32 eligible; 22 completed study to hospital discharge)

4 Observational report to define patient profiles and therapy services in ICU:• consult&treatment

frequency• mobility/ADL’s• ROM/strength• patientsafety

• 50reviewedPT/OTsessionwith19patients


• Studyidentifiedcommonbarriers&provides helpful recommendations to implement PT/OT in ICU setting

• overhalfofpatientsrequiredpost-acuterehabilitation following ICU stay

• 81%ofpatientshadanepisodeofdelirium


retrospective analyses.18,30-32 Two of those studied patients in a postacute environment.30,31

Safety/Adverse EventsOf all studies reviewed, 10 papers reported data concern-

ing untoward events (eg, line removal, extubation), physiolog-ical responses [eg, heart rate (HR), blood pressure (BP), pulse oximetry] and/or need for alteration in medical plan of care (eg, sedative or vasopressor administration). The authors (JA and DM) defined these events as pertaining to patient safety. Asnoted inTable2untowardeventsoccurred in≤4%oftotal patient interactions. The reviewed studies used specific physiologic responses and patient complaints (see Table 3) to initiate and terminate exercise or activity sessions. Bailey et al23 consecutively enrolled patients with respiratory failure

who required mechanical ventilation for >4 days. There were 14 activity-associated untoward events during 1,449 activity sessions, none of which were deemed serious. In the study by Pohlman and colleagues32 a descriptive analysis of the intervention arm of the study by Schweickert et al,20 activ-ity associated adverse events occurred in 16% (80 of 498) of therapy sessions with patients on mechanical ventilation. The authors describe many of the events as “expected physi-ological changes with exercise.” Examples include a HR in-crease greater than 20% of baseline (21 of 498 or 4.2 %), and a respiratory rate (RR) greater than 40 breaths per minute (20 of 498 interactions or 4.0%). Activity sessions were halted due to exceeding the predetermined criteria (see Table 3).

Overall, the most commonly cited adverse event was oxygen desaturation. These episodes were of short dura-

Table 3. Criteria for Terminating a PT/ OT Mobilization Session as Summarized from the Literature Heart Rate:• >70%APMHR• >20%decreaseinrestingHR• <40beats/minute;>130beats/minute• Newonsetdysrhythmia• Newanti-arrhythmiamedication• NewMIbyECGorcardiacenzymes

Pulse Oximetry/ SpO2:• >4%decrease• <88%-90%

Blood Pressure:• SBP>180mmHg• >20%decreaseinSPB/DBP;orthostatichypotension• MAP<65mmHg;>110mmHg• Presencesofvasopressormedication;newvasopressororescalating

dose of vasopressor medication

Mechanical Ventilation:• FIO2 ≥ 0.60• PEEP≥10• Patient-ventilatorasynchrony• MVmodechangetoassist-control• Tenuousairway

Respiratory Rate:• <5breaths/minute;>40breaths/minute

Alertness/ Agitation and Patient symptoms:• Patientsedationorcoma–RASS≤-3• Patientagitationrequiringadditionorescalationofsedative

medication; RASS >2• Patientc/ointolerableDOE• Patientrefusal

PT=physical therapy, OT=occupational therapy, HR= heart rate, RR=respiratory rateSPo2=saturation of peripheral oxygen, MI=myocardial infarction, ECG=electrocardiogram BP=blood pressure, SBP/DBP=systolic/diastolic blood pressure, MAP=mean arterial blood pressureFiO2=fraction of inspired oxygen, Peep=positive end expiratory pressure, MV=mechanical ventilation APMHR=age predicted maximum heart rate, RASS=Richmond Agitation Sedation Scale, DOE=dyspnea on exertion

Needham DM. 201026

Prospective Quality Improvement (QI) project

Case controlled

(N = 57 total (27 pre QI; 30 post QI)

3B Functional mobility

• Supine-to-sit

• Sittingedgeofbed

• Standing

• Transfers

• Ambulation

Pre-QI: 210 PT/ OT treatment session

• Noevents

QI Period: 810 PT/ OT treatment sessions

• 4events(rectalorfeedingtubedisplacement)


• IncreasednumberofPT/OTconsults&treatment sessions incorporating more advanced mobilization activities without increased incidence of adverse events

Bourdin G. 2010 28 Prospective

One-group repeated measurements

N=20 consecutive patients

4 Functional mobility training (chair sitting; tilting up with & without arms supported, ambulation)

424 interventions with 13 events (3%)

• lossofmuscletonewithoutfall

• extubation;desaturation<88%,hypotension


• Studyemphasizesthephysiologicresponses associated with a variety of mobilization procedures

• Studydeterminedbarrierstorehabilitation

• Studydeterminedthatearlymobilizationwas feasible and safe

◊ Included use of equipment to facilitate upright/ assisted standing

MV=mechanical ventilation, PT=physical therapy, OT=occupational therapy, FiO2=fraction of inspired oxygen , HR= heart rate, HTN=hypertensionBP=blood pressure, SBP=systolic blood pressure, MAP=mean arterial pressure, SPo2=saturation of peripheral oxygen, ICU=intensive care unitABG=arterial blood gas, OOB=out of bed, RN=nurse , s/p=status post, c/o=complains of, RCT=randomized controlled trial, Ther ex.=therapeutic exercise, ROM=range of motion, UE/LE=upper/lower extremity, ADL=activity of daily living, GIB=gastrointestinal bleed, HD=hemodialysis , ETT=endotracheal tube


Table 4. Outcomes of ICU MobilizationStudy Study Design

(N= subjects)Levels of Evidence (Sackett)

Physical Therapy Interventions

Functional Outcomes Other notable findings

Strength/ ROM QOL Mobility

Martin UJ. 200530 Retrospective


N = 49 enrolled; 49 completed study)

4 Treatment group underwent UE/ LE ther ex., trunk control tasks; cycle ergometry, inspiratory muscle training and functional training x 5 days/ week

Increased UE/ LE strength as measured on 5 point scale; increased inspiratory muscle force (maximal NIF)

N/A All patients bedridden initially; Following rehab program, patients demonstrated higher scores on FIM for supine <> sit and sit<> stand but no differences for ambulation/ stairs

• settingisapostintensivecareunit(ventrehab unit; MV > 14 days)

• negativecorrelationbetweenUEstrength at admission and weaning duration

• nocontrolgroup

Chiang LL. 200622 Prospective

RCT

(N = 39 enrolled; 32 completed study) (15 control; 17 treatment group)

2B Treatment group underwent UE/ LE ther ex., breathing retraining ex., and functional training x 5 days/ week x 6 weeks

Increased UE/ LE strength (hand-held dynamometry) and respiratory muscle force (PImax & PEmax)

N/A Treatment group had higher scores on FIM and Barthel Index following 3 and 6 weeks of PT intervention

• settingisapost-ICU◊ median MV days≥ 46◊ may not be applicable to acute

care/ ICU• increasedventfreetimeintreatment

group• moderatecorrelationb/wlimbstrength

and ADL performance and mobility • impairedcognitivestatusatabaseline

improved throughout intervention period

• smallsamplesize

Bailey P. 2007 23 Prospective


(N=103 patients)

4 Twice daily PT/ activity session

N/A N/A Median distance ambulated by survivors was 64.6 meters

• Studyprovidescriteria(neurologic/circulatory/ respiratory) for initiating mobility

• StudyverifiesthatearlymobilizationofICU patients can be achieved

• Increasednumberofcomorbidconditions did not influence ambulatory status

• AmbulationdistanceatICUdischargemay predict post-acute d.c. destination

• Nocontrolgroupforcomparison

Morris PE. 200825 Prospective

Cohort study

(N=330; 165 intervention; 165 “usual” care”)

2B Mobilization program implemented 7 days/ week by “mobility team” consisting of PT, critical care RN and nursing assistant

N/A N/A Intervention group reached mobilization milestones sooner (eg: day to first OOB)

• Protocolformobilizationiswelldefined

• Interventiongrouphadshorterhospital& ICU lengths of stay potentially leading to cost savings

• InterventiongrouphadincreasedPTfrequency throughout hospital length of stay

• Onaverage,protocolpatientsinitiatedOOB 7 days earlier compared to usual care

• NodifferencesinMVdurationord.c.destinations

• Nonrandomized

Thomsen GE. 200824

Prospective


[N = 104 patients (91 Survivors)]

4 Functional mobility training (ROM; sitting at edge of bed and OOB; ambulation)

N/A N/A More advanced mobilization activities (OOB transfers & sitting; ambulation) increased within 24 hours of transfer to the unit where mobilization is emphasized

• Meandistanceofambulationatd.c.was ≥ 200 feet

• Sedatives,evenintermittentsedationadministration decreased likelihood of ambulation

• femalegenderandreducedillnessseverity (ie, APACHE score) associated with greater ambulation

Schweickert WD. 200920

Prospective

RCT

(N=104; all patients completed study)

1B Treatment group underwent progressive UE/ LE ther ex., trunk control/ balance activities and functional training including ADL’s x 7 days/ week

No difference in UE/LE strength as measured by MRC or hand grip

N/A Increased % of intervention group returned to functional baseline as defined by FIM and Barthel Index and had greater unassisted walking distance at hospital d.c.

• Earlymobilizationassociatedwithreduced incidence of delirium and ventilator free days

• MVdidnotprecludeacquisitionofmobility milestones

• StudyincludedperformanceofADL’s• 87%oftherapysessionscompleted• NodifferencesinICUorhospital

length of stay• NodifferenceinICU-acquired

weakness

Burtin C. 200921 Prospective

RCT

(N = 90 enrolled; 67 completed) (36 control; 31 treatment group)

2B Both groups received UE/ LE ther ex and functional training x 5 days/ week

treatment group had additional cycling session x 20 minutes total duration x 5 days/ week

Hand held dynamometry: no difference in quadriceps muscle force at ICU d.c. but increased quadriceps muscle force noted at hospital d.c.;

No difference in hand grip strength at either time point

Improved QOL (SF-36 PF) at time of hospital d.c.

No differences at time of discharge from ICU.

Treatment group had increased 6 MWT distance and at time of hospital discharge

• moderatecorrelationbetweenquadriceps strength and 6 MWT and SF-36

• trendsnotedforproportionofpatientswho were ambulatory and/ or discharged home (study not adequately powered)

• nodifferencesinabilitytotransferfromsit<> stand or ambulate independently between groups

• nodifferencesinweaningtime,lengthof ICU or hospital stay


tion lasting less than 3 minutes. In studies that reported on adverse events, accidental removal of patient support equipment happened rarely (<1%) further highlighting the safety of patient mobilization. Burtin et al21 reported one Achilles tendon rupture in their intervention group that used in-bed cycle ergometry. There were no serious adverse events that required life saving measures or alterations in the patient’s medical care.

FUNCTIONAL OUTCOMESMuscle Strength

Extremity muscle strength was measured by hand-held dynamometry or manual muscle testing [eg, Medical Re-search Council (MRC) scoring] in 4 studies as noted in Table 4 and defined in Table 5. Medical Research Council scores, handgrip, and extremity strength did not differ at time of discharge from the ICU20,21 but Burtin et al21 showed increased quadriceps muscle force at time of hospital dis-

charge. In postacute settings where patients were mechani-cally ventilated for a minimum of 14 days prior to transfer, strength gains were observed. In one study,30 subjects were mechanically ventilated for a median duration of 46 to 52 days (22.8 ± 80.8 days) and demonstrated upper extremity/lower extremity (UE/ LE) strength gains measured by dyna-mometry. In another study30 patients were mechanically ventilated for 18.1 ± 7 days and also demonstrated UE/LE strength gains by manual muscle testing (MMT). Both stud-ies found increases in respiratory muscle strength.

Functional Mobility: The most frequently described func-tional outcomes assessed were: time to mobility milestones [eg, time to first out of bed (OOB), standing]; ambulation distance,24 the Barthel Index,33 the Functional Indepen-dence Measure (FIM)34 or select parts of the FIM [Function-al Status Score in the ICU (FSS-ICU)].4 The FSS-ICU, similar to the FIM, rates functional activities between 1 (total assist)

Needham DM 201026

Prospective QI project

Case controlled

(N = 57 total (27 pre QI; N=30 post QI)

3B Functional mobility training (supine to sit; sitting at edge of bed; OOB transfers; ambulation)

N/A N/A Greater percentage of patients engaged in more advanced mobilization (i.e.: OOB activities)

Additional QOL goals accomplished:• increasenumberofPT/OTconsults&

interventions; reduction in missed PT/ OT sessions

• reduceduseofsedativedrugs• increasedalertnesswithreduced

delirium• reducedICUandhospitalLOS

Morris PE 201118 Retrospective

cohort analysis of survivors from prior study*** (see Morris 2008)

N = 258 of 280 survivors of acute respiratory failure

2B Mobilization program implemented 7 days/ week by “mobility team” consisting of PT, critical care RN and nursing assistant

N/A N/A Patient participation in an ICU mobilization program was associated with reduced hospital readmission or death in the year following hospitalization

• Studydeterminedadditionalvariablesassociated with hospital readmission including female gender, co-morbidties, and tracheostomy

• >50%ofsurvivorswillhaveareadmission or die in the year following hospitalization

Montagnani G 201131

Retrospective

Non-equivalent Pretest-Posttest Control Group Design

(N= 56 weaning program (WP); N= 63 pulmonary rehab (PR))

4 WP patients performed UE/ LE ther. ex including UE/ LE cycling and mobilization 6 days/week

PR subjects exercise on treadmill/ UE/ LE ergometer and low intensity PRE’s daily x 15- 21 days

N/A Dyspnea scores declined in both groups

Both groups demonstrated improvement in FIM scores

• Settingwaspost-acute/long-termweaning center

• Includedobjectivemeasurementofdyspnea

• FIMmaybeusefuloutcometoolinthisnovel setting for patients who require prolonged MV◊ Patients who are deemed

“difficult to wean”• Notrandomizedwithsmallsamplesize

PT=physical therapy, OT=occupational therapy, MV=mechanical ventilation, NIF=negative inspiratory force, QOL=quality of life, N/A=not applicableFIM=functional independence measure, PImax=peak inspiratory pressure, PEmax=peak expiratory pressure, HR= heart rate, ICU=intensive care unitD.C.=discharge, c/o=complains of, s/p=status post, OOB=out of bed, RN=nurse, RCT=randomized controlled trial, LOS=length of stayAPACHE=acute physiology and health evaluation score, 6MWT=six minute walk test, MRC=Medical research council SF-36=short form health survey

Table 5. Medical Research Council (MRC) Scoring System for Muscle Strength*Score Description

0 No visible contraction Movements Assessed

1 Visible muscle contraction, but no limb movement Upper Extremity: Lower Extremity:

2 Active movement, but not against gravity Shoulder abduction Hip flexion

3 Active movement against gravity Elbow flexion Knee Extension

4 Active movement against gravity and resistance Wrist extension Dorsiflexion

5 Active movement against full resistance

Maximum score: 60 (4 limbs; 3 movements per extremity with maximum score of 15 points per limb)Minimum score: 0 (quadriplegia)

*Adapted from Schweickert and Hall. ICU-Acquired Weakness. Chest. 2007;31:1541-1549.


and 7 (complete independence). A score of 0 is assigned if a patient is unable to perform a task. Only 5 of the items from the FIM are included: (1) rolling, (2) transfer from su-pine to sit, (3) sitting at the edge of bed, (4) transfer from sit to stand, and (5) ambulation are combined in the cumula-tive FSS-ICU score.4

Mobility milestones were accomplished earlier in the intervention groups than the comparison groups in 4 stud-ies.20,24-26 Compared to controls, ambulation frequency was greater in the study by Thomsen et al24 and ambulation dis-tance was greater at time of hospital discharge in the stud-ies by Schweickert et al20 and Burtin et al.21

Objective measures such as the FIM & Barthel Index improved in the intervention groups at time of hospital discharge but without significant differences at time of ICU discharge in the study by Schweickert et al.20 In the postacute care setting, bed mobility and transfers were im-proved in 3 studies22,30,31 but ambulation/locomotion were only improved in the studies by Chiang et al22 and Montag-nani et al.31

Quality of Life & Patient Symptoms: Burtin et al21 noted improvements in the physical functioning (PF) subscore of the SF-36 at time of hospital discharge but quality of life (QOL) was not reported for the transition from ICU to ward. Dyspnea was measured in the postacute care set-ting in the study by Montagnani et al.31 These patients were hospitalized for approximately 40 days prior to postacute admission, had tracheostomies, and required prolonged mechanical ventilation. The symptom of dyspnea was re-duced following the rehabilitation period.

DISCUSSIONThe focus of critical care medicine in the ICU is res-

toration of physiological or hemodynamic stability and prevention of death. The historical approach to achieve these goals has included long periods of immobility and bedrest. The impact of life-sustaining ICU technology on patients that have required sedation, long-term mechani-cal ventilation, and bedrest has been profound with re-spect to severe muscle weakness, functional impairments, and loss of quality of life.15 By understanding the nega-tive sequella of ICU-induced bed rest, investigators are attempting to correct these derangements by reducing the dosage and frequency of sedative medication and mobi-lizing critically ill patients once hemodynamic stability has been achieved. We have reviewed published reports that have studied this clinical approach.

Safety: Studies included in this review persuasively con-clude that the mobilization of critically ill but stable pa-tients in the ICU and immediate postacute environment, who have required a period of mechanical ventilation, can be done safely with minimal risk to the patient. Although most studies included patients receiving 4 or more days of mechanical ventilation, Pohlman et al20 demonstrated the safety of physical therapy intervention occurring within two days of intubation. The most common untoward event

was transient oxygen desaturation that was attenuated by rest and increasing the FiO2 delivered to the patient. Line dislodgment and/or accidental extubation, frequently men-tioned dangers of mobilization, happened rarely, further highlighting the safety profile of patient mobilization.

In all studies, hemodynamic, respiratory, and cognitive criteria were established a priori to ensure patient safety (Table 3). These criteria guided the clinicians to determine patient eligibility for mobilization and, it is presumed, lim-ited untoward events by providing the treating physical therapist and/or occupational therapist parameters to guide the intensity of the mobilization sessions. Mobilization was loosely described in most studies citing therapist discretion for advancing activities based on patient tolerance and sta-bility. However, Stiller et al27 provided an algorithm for initiating and terminating therapy sessions based on physi-ologic and laboratory data while Morris et al25 provided an algorithm for mobility progression based on patient’s physi-cal capabilities.

Overall activity-induced increases in HR, BP, respiratory rate (RR), tidal volume, and minute ventilation were within acceptable ranges, challenging the perception that patients in the ICU are “too sick” to participate in mobilization activi-ties.4,27,28 As noted multiple studies have reported on safety and feasibility but the lack of reported negative events could reflect a bias of nonreporting of adverse incidents.

Muscle Strength: Although it is generally accepted that pa-tients in critical care settings for prolonged periods of time are often “bed ridden,” deconditioned, and weak, muscle strength was infrequently reported as an outcome measure in the reviewed studies. In studies that did address muscle force production, strength was not significantly improved in the ICU20,21 but did improve by the time of discharge from the hospital.21 Interestingly, strength was consistently improved in the postacute care setting.22,30

Functional Mobility: The literature reviewed supports improvements in functional mobility following early and progressive physical therapy/occupational therapy (PT/ OT) in the ICU but the measurement of this outcome was not uniform across the literature. For example, as mentioned in the results section, variability of outcome measurements included acquisition of mobility milestones,18,20,21,23,24,26 FIM,20,22,30,31 FSS-ICU,4 and the Barthel Index.33 Time to mobility milestones was reduced and patient participation in advanced mobilization activities occurred more fre-quently in ICUs where mobilization and PT/ OT were em-phasized.20,24-26 Within the ICU setting, objective measures such as the FIM & Barthel Index were used infrequently although two of the cited studies used these tools.4,20

The FIM and Barthel Index scores improved in the inter-vention group in the study by Schweickert et al20 with over 59% of patients achieving functional independence (FIM ≥ 5) compared to 35% of the control group at time of hos-pital discharge. The FIM scores also improved following rehabilitation in the postacute setting.22,30,31 Use of the FIM, or the related FSS-ICU4 to measure patient disability and to


compare functional outcomes is attractive since the tool is well known to rehabilitation professionals. However, the validity and reliability of this tool has not been established in the ICU setting.

Quality of Life & Patient Symptoms: Quality of life and patient symptoms were seldom measured within the ICU. One study21 measured QOL and one study measured pa-tient’s symptoms.31 Burtin et al21 demonstrated improve-ments in the physical functioning domain of the SF-36 at hospital discharge while Montagnani et al31 reported re-duced patient dyspnea. As noted in the introduction, qual-ity of life and neuropsychological impairments such as depression, anxiety, and posttraumatic stress disorder are negatively impacted by prolonged mechanical ventilation and ICU duration. Rehabilitation in the ICU and its influ-ence on these factors should be an area of future research.

The physiology and complications of bed rest are well understood. Intensive care unit-acquired weakness and functional dependency are recognized as unfortu-nate consequences of prolonged duration in ICUs and mechanical ventilation. Although sedative medications are used to reduce metabolic energy demand for patients in respiratory failure they inhibit participation in exercise and functional activity and often cause disturbances in levels of arousal. Despite the inherently complex envi-ronment and challenges that face critical care teams, in-cluding the human resources required to safely mobilize patients, feasibility and safety has been demonstrated as noted in Table 2. Critically ill patients can exercise, sit up, transfer to bedside chairs, and ambulate in the hall-ways; however, few published papers have randomized and controlled this intervention. The work of Schweickert et al,20 Burtin et al,21 and Chiang et al22 have found that participation in monitored programs of physical activity can lead to statistically significant improvements in am-bulation independence, reduced duration of mechanical ventilation, better ability to perform self care activities, and improved respiratory function.

CONCLUSION/IMPLICATIONS FOR FUTURE RESEARCHIn summary, the body of evidence that has studied the

mobilization of critically ill patients is small. The few ran-domized controlled trials include a total of only 171 pa-tients limiting the strength of evidence. Based on the stud-ies reviewed, early physical therapy and ICU mobilization is feasible and safe. Acquisition of mobility milestones is enhanced in ICUs that promote early rehabilitation. Im-provements in quality of life and muscle strength cannot be determined at this time.

In reviewing the literature, there are several questions that must be addressed. These questions include, but are not limited to: (1) How do published papers reflect current practice as mobilization has been reported in a small per-centage of ICUs? (2) What is the appropriate level of clinical expertise or experience required to safely work in a critical care environment? (3) What intensity, frequency, and dose

of physical activity will lead to optimal patient outcomes? (4) What generalization to other patient populations can be made since the majority of patients studied are found in medical ICUs? (5) Should all patients who require me-chanical ventilation or ICU admission be referred to physi-cal therapy? And (6) Are there optimal patient populations who would benefit most from early mobilization, as well as populations for whom physical therapy is clearly contra-indicated? The answer to these questions will provide an evidence-based approach to optimize patient outcomes for the critically ill patient.

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barriers and benefits. Crit Care Clin. 2007;23:1-20.2. Truong AD, Fan E, Brower RG, Needham DM.

Mobilizing patients in the intensive care unit-from pathophysiology to clinical trials. Crit Care. 2009;13:216.

3. Kress JP, Clinical trials of early mobilization of critically ill patients. Crit Care Med. 2009;37[Suppl.]:s442-s447.

4. Zanni JM, Korupolu R, Fan E, et al: Rehabilitation therapy and outcomes in acute respiratory failure: an observational pilot project. J Crit Care. 2010;25(2):254-262.

5. Hodgin KE, Nordon-Craft A, McFann KK, Mealer ML, Moss M. Physical therapy utilization in intensive care units: Results from a national survey. Crit Care Med. 2009;37(2):561-566; quiz 566-568.

6. Norrenberg M, Vincent JL. A profile of European in-tensive care unit physiotherapists. Intensive Care Med. 2000;26:988-994.

7. Nava S, Ambrosino N. Rehabilitation in the ICU: the Eu-ropean phoenix. Intensive Care Med. 2000;26:841-844.

8. Dejonghe B, Sharshar T, Lefaucheur JP, et al. Paresis ac-quired in the intensive care unit: A prospective multi-center study. JAMA. 2002;288:2859-2867.

9. Stevens RD, Dowdy DW, Michaels RK, et al. Neuromus-cular dysfunction acquired in critical illness: a systemat-ic review. Intensive Care Med. 2007;33(11):1876-1891.

10. Herridge MS, Cheung AM, Tansey CM, et al. One year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med. 2003;348:683-693.

11. Cheung AM, Tansey CM, Tomlinson G, et al. Two-year outcomes, health care use and costs in survivors of ARDS. Am J Resp J Crit Care Med. 2006;174:538-544.

12. Herridge MS, Tansey CM, Matte A, et al. Functional disability 5 years after acute respiratory distress syn-drome. N Engl J Med. 2011;364:1293-1304.

13. Harper CM, Lyles YM. The physiology and complications of bedrest. J Am Geriatr Soc. 1988;36(11):1047-1054.

14. Bergouignan A, Rudwill F, Simon C, Blanc S. Physical inactivity as the culprit of metabolic inflexibility: evidences from bedrest studies. J Appl Physiol. 2011 Aug 11 (Epub ahead of print).

15. Bloomfield SA. Changes in musculoskeletal structure and function with prolonged bedrest. Med Sci Sports Exerc. 1997;29(2):197-206.


16. Brower RG, Consequences of bed rest. Crit Care Med. 2009;37(10):422-428.

17. Hopkins RO, Spuhler VJ, Thomsen GE. Transforming ICU culture to facilitate early mobility. Crit Care Clin. 2007;23:81-96.

18. Morris PE, Griffen L, Berry M, et al. Receiving early mobility during and intensive care unit admission is a predictor of improved outcomes in acute respiratory failure Am J Med Sci. 2011;341(5):373-377.

19. Centre for Evidence-based Medicine. Levels of Evidence (March 2009) Website. Available at www.cebm.net. Accessed September 26, 2011.

20. Schweickert WD, Pohlman MC, Pohlman AS. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled. Lancet. 2009;373:1874-1882.

21. Burtin C, Clerckx B, Robbeets C, et al. Early exercise in critically patients enhances short-term functional recovery. Crit Care Med. 2009;37(9):2499-2505.

22. Chiang LL, Wang LY, Wu CP, Wu HD, Wu YT. Effects of physical training on functional status in patients with prolonged mechanical ventilation. Phys Ther. 2006;86:1271-1281.

23. Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35(1):139-145.

24. Thomsen GE, Snow GL, Rodriguez L, Hopkins RO. Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med. 2008;36(4):1119-1124.

25. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36(8):2238-2243.

26. Needham DM, Korupolu R, Zanni JM, et al: Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil. 2010;91:536-542.

27. Stiller K, Phillips, AC, Lambert P. The safety of mobilisa-tion and its effects on haemodynamic and respiratory status of intensive care patients. Physio Theory Pract. 2004;20:175-185.

28. Bourdin G, Barbier J, Burle JF, et al. The feasibility of early physical activity in intensive care unit patients: A prospective observational one-center study. Resp Care. 2010;55:400-407.

29. Zafiropoulus B, Allison JA, McCarren B. Physiological responses to the early mobilization of the intubated, ventilated abdominal surgical patient. Austr J Physio-ther. 2004;50(2):95-100.

30. Martin UJ, Hincapie L, Nimchuk M, Gaughan J. Criner GJ. Impact of whole-body rehabilitation in patients re-ceiving chronic mechanical ventilation. Crit Care Med. 2005;33(10):2259-2265.

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ventilation is difficult. Phys Ther. 2011;91(7):1109-1115.

32. Pohlman, MC, Schweickert WD, Pohlman AS et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med. 2010;38:2089-2094.

33. MahoneyFI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:61-65.

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Respiratory and Hemodynamic Responses to Mobilization of Critically Ill Obese Patients

Arzu Genc, Assoc. Prof, PT;1 Seher Ozyurek, MSc, PT;1 Ugur Koca, Assoc. Prof, MD; 2 Ali Gunerli, Prof, MD 2

1School of Physical Therapy and Rehabilitation, Dokuz Eylul University, Izmir, Turkey2Faculty of Medicine, Department of Anesthesiology, Dokuz Eylul University, Izmir, Turkey

Address correspondence to: Seher Ozyurek, MSc, PT, School of Physical Therapy and Rehabilitation, Dokuz Eylul University, Izmir, Turkey, Ph: +90 232 412 49 29, Fax: +90 232 277 50 30 ([email protected]).

ABSTRACTPurpose: The aim of this study was to investigate the effects of mobilization on respiratory and hemodynamic parameters in critically ill obese patients. Methods: Critically ill obese pa-tients (n=31) were included in this retrospective study. Data were collected from patients’ files and physiotherapy records of mobilization sessions. Heart rate (HR), systolic/diastolic/mean blood pressure, respiratory rate (RR), and percutaneous oxygen saturation (SpO2) were recorded. Cardiorespiratory parameters were collected just prior to the mobilization, just after the completion of the mobilization and after 5 minutes recovery period. Respiratory reserve was calculated before and after the mobilization. Results: A total of 37 mobiliza-tion sessions in 31 obese patients (mean age: 63.3 years, mean BMI: 32.2 kg/m2) who received physiotherapy were analyzed. Respiratory rate increased significantly after the completion of the mobilization compared to initial values (p < 0.05). SpO2 significantly increased (p < 0.05) and all other parameters remained similar (p > 0.05) compared to initial values after the recovery period. Mobilization resulted in a significant increase in respiratory reserve (p < 0.05). Conclu-sion: Early mobilization in intensive care unit promotes respi-ratory reserve in obese patients. We found that mobilization can be performed safely in critically ill obese patients if car-diorespiratory parameters are continuously monitored.

Key Words: obesity, mobilization, critically ill patients, physiotherapy

INTRODUCTION AND PURPOSEObesity is among the most serious public health prob-

lems1,2 that affects many people and often requires multidis-ciplinary treatment.3 There is overwhelming evidence that the prevalence of obesity, defined as having a body mass index (BMI) of ≥ 30 kg/m2,4 is increasing worldwide.2,5

Obesity is associated with increased risk of chronic dis-eases, secondary medical complications, and reduced health related quality of life.6 Approximately one-third of patients admitted to intensive care units (ICU) are obese and nearly

7% are morbidly obese.7,8 The term morbid obesity refers to adults with BMI greater than or equal to 40 kg/m2.2

Several studies have investigated the effect of obesity on outcome in ICU setting.9-14 Many of these studies have shown increased morbidity and mortality.12-14 Data on out-comes of critically ill patients indicated that obese patients were more likely to have complications including acute respiratory distress syndrome (ARDS),10,12 septic shock,14 acute renal failure,10,12 and acquired infection.12,14 Besides these severe events, obesity is associated with increased risk of ARDS11 and increased length of ICU stay.11-14

As patients survive chronic illness, immobilization complications such as muscle weakness and atrophy, con-tractures, decreased cardiac reserve, venous thromboem-bolism, and orthostatic hypotension are more apparent.15

For these reasons, physiotherapy interventions should be initiated as early as possible after the acutely ill patient is admitted to the ICU.16 Many studies showed that mobiliza-tion of critically ill patients in the earliest days of critical care can result in improved patient outcomes.17-20

Recently, there has been an interest in early mobiliza-tion of ICU patients. Although many authors agree that mo-bilization of acutely ill patients is feasible and safe;20-22 to our knowledge, there are no studies that were specifically implemented in critically ill obese patients.

The aim of this retrospective study was to investigate the effects of mobilization on respiratory and hemodynam-ic parameters in critically ill obese patients. We focused on whether patients’ responses to mobilization were within the normal ranges.

METHODSDesign

The study was retrospective. Data were collected from patients’ files and physiotherapy evaluation forms.

Patient and settingsCritically ill obese patients who received mobilization

sessions in their physiotherapy program during the ICU stay in the 18-bed Anesthesiology and Reanimation Intensive Care Unit of the university hospital between January 2007 and January 2010 were included in the study. This study was approved by the Institutional Review Board at Dokuz Eylul University.

Patients were classified as obese according to the defi-nitions of the World Health Organization criteria4 based on


BMI formula: BMI= body weight (kg)/height2 (m2). Obese patients were defined as having BMI of ≥ 30.00 kg/m2.

Inclusion criteria for receiving mobilization sessions consisted of stable conscious state and able to understand and follow commands appropriately, hemodynamically stable (not requiring inotropes), body temperature < 38°C, hemoglobin levels stable and > 7 g/dL, percutaneous oxy-gen saturation (SpO2) > 90%, mean blood pressure (MBP) > 60 mmHg, no orthopedic and neurological contraindica-tions.23

Mobilization protocolThe standard mobilization protocol is that mobilization

is begun as soon as patients’ cardiorespiratory system is sta-ble (as defined above). Per hospital standard protocol, mo-bilization was begun as soon as the patients’ cardiorespira-tory system was stable (as defined above). Hemodynamic and respiratory parameters were continuously recorded at all stages of mobilization sessions. The mobilization pro-gression was based on the patients’ general clinical status, ability, and willingness.

Physiological responses were monitored continuously as the patient progressed through the mobilization protocol in order to prevent adverse effects of mobilization.

The following criteria were chosen as intolerance findings:• ≥ 20 mmHg increase or decrease in systolic blood

pressure (SBP)/diastolic blood pressure (DPB),• ≥ 20 beats/minute increase or decrease in heart rate

(HR),• SpO2 < 90%, and• paradoxical breathing, dizziness, perspiration, and

faintness.18

Intolerance findings were recorded by the physical ther-apists to evaluate the safety of patients and patients’ abnor-mal responses to mobilization.

Data collection and outcome measureOne physiotherapist specialized in intensive care col-

lected the information retrospectively from the obese pa-tients’ files (see Table 1). Data were collected in 3 categories: patients’ demographics (age, gender, height, body weight, BMI), patients’ medical information, and physiotherapy re-cords of mobilization sessions during their ICU stay.

Hemoglobin levels, platelet counts, white cell counts, and blood glucose levels were collected from the most re-cent blood analyses and body temperature was recorded from the monitor (Draeger Medical Systems Inc, U.S.A) be-fore mobilization.

The following hemodynamic and respiratory param-eters were taken from the monitor: HR, SBP, DBP, MBP, re-spiratory rate (RR), and SpO2. Measurements were collect-ed in 3 stages: (1) just prior to the mobilization in supine position (premobilization), (2) just after the completion of the mobilization when the patient had been returned to the supine position (postmobilization), and (3) after 5 minutes recovery period (5 minutes recovery).

The ratio of partial pressure of oxygen in arterial blood to the inspired fraction of oxygen (PaO2/FiO2) was calcu-

lated from the most recent arterial blood gas samples for assessing the respiratory reserve before and after the mobi-lization. Respiratory reserve reflects oxygenation.23

Data analysisThe statistical package SPSS 15.0.0 for Windows (SPSS

Inc., Chicago, IL, USA) was used for statistical analysis. Level of significance was set at p < 0.05. All continuous variables were evaluated for normality using Kolmogorov-Smirnov test with Lilliefors Significance Correction. Con-tinuous variables were expressed as mean ± standard de-viation (if data were normally distributed) or as medians in combination with quartiles and percentiles (if data were not normally distributed). Mobilization data were analyzed with a one way repeated measure analysis of variance (ANOVA). Statistically significant changes were further an-alyzed with post-hoc Bonferroni t-test. To compare changes in respiratory reserve between before and after mobiliza-tion, paired sample t-test was performed.24

RESULTSRetrospective analysis of 31 patients’ files who received

mobilization in their physiotherapy program during the ICU stay fulfilled all aspects of the study. A total of 31 obese patients received 37 mobilization sessions in ICU. Baseline characteristics of the patients are summarized in Table 1.

All mobilization sessions were performed after patients were extubated. Mobilization events included 26 (70.3%) sitting on the edge of the bed, 3 (8.1%) standing, 8 (21.6%) walking to the chair and sitting in the chair.

A total of 7 intolerance findings were recorded in 6 patients. One patient had 2 intolerance findings. Intoler-ance findings included 4 increase or decrease in SBP (20 mmHg or more), 3 increase or decrease in HR (20 beats/minute or more). Despite the intolerance findings, no de-terioration in clinical status occurred during the mobiliza-tion sessions.

Effects of mobilization on hemodynamic parametersThe results showed that HR was significantly different

when 3 mobilization stages were compared (F= 3.79, p= 0.049). Heart rate significantly decreased in the 5 minute recovery period when compared with postmobilization values (p < 0.05). There were no significant differences in other hemodynamic parameters (p > 0.05) (Table 2).

Effects of mobilization on respiratory parameters Significant changes were seen in RR (F = 17.35, p = 0.00)

with progression of mobilization. Respiratory rate significant-ly increased from premobilization to postmobilization. A sig-nificant RR reduction was seen in the 5 minute recovery pe-riod when compared with postmobilization values (p < 0.05).

Mobilization caused a significant change in SpO2 (F= 4.11, p= 0.02). After a 5 minute recovery period, SpO2 sig-nificantly increased compared with premobilization values (p < 0.05) (Table 2). Mobilization resulted in a significant increase in respiratory reserve when compared with pre-mobilization values (t = -5.440 p = 0.00) (Table 2).


DISCUSSIONIn this retrospective study, we investigated the hemody-

namic and respiratory responses to early mobilization and effects of the mobilization on oxygenation in critically ill obese patients. Although mobilization resulted in signifi-cant increases in RR after mobilization, all parameters were similar in the 5 minute recovery period when compared with initial values, except for SpO2. Increases in RR may be due to the patients’ efforts to compensate for the increased physical activity. It was an expected response to increased work of breathing. Nonsignificant HR, SBP, DBP, and MBP increases were seen during postmobilization period. This result showed that mobilization did not put excess hemo-dynamic stress on obese patients. Significant increase was observed in SpO2 in the recovery period when the patient was taken back to supine position in bed. Additionally, we found that respiratory reserve significantly improved after mobilization. Although the 7 of 37 mobilization sessions had intolerance findings, mobilization did not result in de-terioration in clinical status. On the two of 7 intolerence findings, the magnitude of SBP or HR increases were very small when compared to chosen intolerance findings (in one patient: 21 beats/minute increase in HR, in the other patient: 21 mmHg increase in SBP). No specific interven-tion was applied during mobilization to stabilize cardiore-spiratory parameters. Patients’ hemodynamic and respirato-ry responses to mobilization were within the normal value.

The main finding of the present study is that mobiliza-tion can be performed safely in critically ill obese patients if cardiorespiratory parameters are continuously monitored. This finding is similar to other mobilization studies,18,20-22 which investigated the effects of mobilization in critically ill patients with other diagnosis.

There are several outcome studies investigating the ef-fect of obesity in ICU.9-11 It is well known that obesity is related to increased morbidity and mortality.12-14 In the lit-erature, it is shown that early mobilization improves func-tional outcomes in critically ill patients.17-20 Although mo-

Table 1. Baseline Characteristics of the PatientsAge (years)

Mean ± SD 63.35±12.25

Range 38.00-83.00

Gender [n(%)]

Male 15 (48.4%)

Female 16 (51.6%)

Body weight (kg)

Mean ± SD 87.48±11.78

Range 70.00-120.00

Height (cm)

Mean ± SD 164.54±9.79

Range 145.00-184.00

BMI (kg/m2)

Mean ± SD 32.24±2.53

Range 30.04-39.56

Diagnosis at ICU admission [n(%)]

Medical 3 (9.7%)

Surgery 28 (90.3%)

Body temperature (0C)

Mean ± SD 36.97±0.38

Range 36.00-37.70

Hemoglobin levels (g/dL)

Mean ± SD 10.69±1.75

Range 7.10-13.70

Platelet counts (cells/mm3)

Mean ± SD 214.229±128.587

Range 51.000-621.000

White cell counts (cells/mm3)

Mean ± SD 12.070±3.009

Range 5.600-18.300

Blood glucose levels (mg/dL)

Mean ± SD 161.21±48.65

Range 101.00-286.000

Table 2. The Comparison of Hemodynamic and Respiratory Parameters between Premobilization, Postmobilization, and Recovery Period (mean ± standard deviation)

Premobilization Postmobilization Recovery p

HR (beat/minute) 91.56 ±17.50 94.45±15.97 90.40±14.91† 0.049

SBP (mmHg) 130.94±15.89 134.08±17.85 130.72±16.68 0.194

DBP (mmHg) 70.00±12.30 72.56±12.80 69.56±11.63 0.081

MBP (mmHg) 91.48±14.92 94.37±14.75 90.56±13.88 0.119

RR (breath/minute) 23.32±4.97 25.89±5.51§ 23.29±4.71† 0.000

SpO2* (%) 98.0(95.5-100.0)

99.0(96.0-100.0)

99.0§

(96.5-100.0)0.020

PaO2/FiO2 230.15±85.80 276.82±99.46 - 0.000a

HR: heart rate, SBP: systolic blood pressure, DBP: diastolic blood pressure, MBP: mean blood pressure, RR: respiratory rate, SpO2= percutaneous oxygen saturation, %=percent, PaO2/FiO2: the ratio of partial pressure of oxygen in arterial blood to the fraction of inspired oxygen†: statistically different from post-mobilization values( p < 0.05).§: statistically different from pre-mobilization values( p < 0.05).p: ANOVA, boldface p values were statistically significant. a: paired sample t- test *: expressed as medians in combination with quartiles and percentiles


bilization is a common practice in most ICUs, there is a lack of data available on obese population. There is only one case report of a morbidly obese patient (BMI: 69 kg/m2)

with multiorgan failure successfully mobilized throughout her ICU stay.25 However that report did not investigate the hemodynamic and respiratory responses to mobilization. To the best of our knowledge, no previous studies have in-vestigated the effects of mobilization on hemodynamic and respiratory parameters in critically ill obese patients. This study is the first research related to early mobilization in obese patients in ICU. Our current findings showed sig-nificant increases in RR after mobilization that returned premobilization values in the recovery period indicating the safety of mobilization as a consequence of normal re-sponses to physical demand. Increases in SpO2 and PaO2/FiO2 reflect the improvement of oxygenation and this result showed that mobilization may improve patient outcomes.

Our obese patients were able to participate in early mo-bilization and the patients demonstrated clinical stability through the ICU stay. Clinical and physiologic stability of a patient has been described as the whole state of neurologi-cal and cardiorespiratory stability.27 Stiller et al23 has outlined the safety issues that should be considered when mobilizing critically ill patients. We selected the inclusion criteria ac-cording to these safety issues. The mobilization progression was based on the patients’ general clinical status, and ability. None of the patients had an adverse event in mobilization.

The majority of the patients (n=28, 90.3%) in the cur-rent study had surgery. Although our patients did not have pulmonary complications, it is well documented in the literature that obese patients have been reported to have a higher incidence of postsurgical pulmonary complica-tions.26 Efficacy and safety of early postoperative mobi-lization in critically ill patients has been shown in prior studies.18,20,27,28 All the patients in Senduran’s18 and Zafi-ropoulos’20 studies and 38.7% of the patients in Stiller’s21 study were postoperative. All of these authors applied early mobilization in ICU and found that mobilization is feasible and safe in patients postsurgery. Our findings sup-port these literature findings.

Zafiropoulos et al20 investigated the effects of mobiliza-tion on respiratory and hemodynamic variables in intubat-ed, ventilated abdominal surgical patients and found that mobilization was associated with significant increases in RR. Similar to Zafiropoulos et al’s20 finding an increase in RR was found in our study after mobilization. We did not include the intubated and mechanically ventilated patients in our study. However, in Stiller’s21 study, 7 patients (22.6%) were intubated, ventilated and they found the same result as well. In contrast with results of Zafiropoulos’,20 Still-er’s,21 and Senduran’s18 studies, we did not find a significant increase in HR after mobilization.

We found that the respiratory reserve of the patients significantly increased after mobilization and SpO2 signifi-cantly increased after 5 minutes recovery. It was expected that the mobilization would enhance the oxygen transport of these patients, due to positive effects of erect position on alveolar ventilation and ventilation/perfusion matching.29

Researchers have speculated that duration of sitting and walking distance may affect the cardiopulmonary respons-es to a recovery period.18 In our study, we did not measure the duration of sitting and walking distance to the chair. This is a limitation of our study.

In our study, only 8 patients (21.6%) managed to walk to the chair and sit in the chair. The majority of our pa-tients (n=26, 70.3%) were seated on the edge of the bed. We think that participation of a large number of subjects in higher level of mobilization stages may affect the results. This may be a limitation of our study.

CONCLUSIONWe conclude that early mobilization is feasible and safe

in critically ill obese patients. Additionally, our study shows the benefits of early mobilization on oxygenation improve-ment. Further randomized-control studies with larger num-ber of patients are needed to contribute new knowledge to physiotherapy literature for the obese population in the ICU setting.

ACKNOWLEDGEMENTSAbstract of this work was presented as a poster presen-

tation in 23rd Annual Congress of the ESICM in Barcelona 2010 and ESICM published the abstracts in Intensive Care Medicine 2010 Supplement 2 which contains abstracts of scientific papers presented at the 23rd Annual Congress of the European Society of Intensive Care Medicine.

REFERENCES1. Thompson D, Eldesberg J, Colditz G, et al. Lifetime he-

alth and economic consequences of obesity. Arch In-tern Med. 1999;159:2177-2183.

2. World Health Organization (WHO). Obesity: prevent-ing and managing the global epidemic. Report of a WHO Consultation on Obesity. Geneva, Switzerland: WHO, 1998.

3. Rippe JM, McInnis KJ, Melanson KJ. Physician involve-ment in the management of obesity as a primary medi-cal condition. Obes Res. 2001;9 Suppl 4:302S-311S.

4. World Health Organisation: Physical Status: The use and interpretation of anthropometry, Geneva, Switzer-land: World Health Organization 1995. WHO Techni-cal Report Series.

5. Björntorp P. Obesity. Lancet. 1997;350:423-426.6. Lean MEJ, Han TS, Seidell JC. Impairment of health

and quality of life using new US Federal Guidelines for the identification of obesity. Arch Intern Med. 1999;159:837-843.

7. Akinnusi M, Pineda L, El Solh A. Effect of obesity on intensive care morbidity and mortality: a metaanalysis. Crit Care Med. 2008;36:151-158.

8. Oliveros H, Villamor E. Obesity mortality in critically ill adults: a systematic review and meta-analysis. Obe-sity. 2008;16:515-521.

9. Frat JP, Gissot V, Ragot S, et al. Impact of obesity in mechanically ventilated patients: a prospective study. Intensive Care Med. 2008;34(11):1991-1998.


10. Anzueto A, Frutos-Vivar F, Esteban A, et al. Influence of body mass index on outcome of the mechanically ven-tilated patients. Thorax. 2011;66(1):66-73.

11. Gong MN, Bajwa EK, Thompson BT, et al. Body mass index is associated with the development of acute res-piratory distress syndrome. Thorax. 2010;65(1):44-50.

12. Yaegashi M, Jean R, Zuriqat M, et al. Outcome of mor-bid obesity in the intensive care unit. J Intensive Care Med. 2005;20:147-154.

13. Goulenok C, Monchi M, Chiche JD, et al. Influence of overweight on ICU mortality: a prospective study. Chest. 2004;125:1441-1445.

14. Bercault N, Boulain T, Kuteifan K, et al. Obesity-related excess mortality rate in an adult intensive care unit: A risk-adjusted matched cohort study. Crit Care Med. 2004;32(4):998-1003.

15. Dittmer DK, Teasell R. Complications of immobilization and bed rest. Part 1: Musculoskeletal and cardiovascular complications. Can Fam Physician. 1993;39:1428-1437.

16. Gosselink R, Bott J, Johnson M, et al. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Soci-ety of Intensive Care Medicine Task Force on Physio-therapy for Critically Ill Patients. Intensive Care Med. 2008;34(7):1188-1199.

17. Scheidegger D, Bentz L, Piolino G, et al. Influence of early mobilisation of pulmonary function in surgical patients. Eur J Intensive Care Med. 1976;2(1):35-40.

18. Senduran M, Yurdalan SU, Karadibak D, et al. Haemo-dynamic effects of physiotherapy programme in inten-sive care unit after liver transplantation. Disabil Reha-bil. 2010;32(17):1461-1466.

19. Morris PE, Griffin L, Berry M, et al. Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure. Am J Med Sci. 2011;341(5):373-377.

20. Zafiropoulos B, Alison JA, McCarren B. Physiological responses to the early mobilisation of the intubated, ventilated abdominal surgery patient. Aust J Physiother. 2004;50(2):95-100.

21. Stiller K, Phillips AC, Lamber P. The safety of mobili-sation and its effect on haemodynamic and respira-tory status of intensive care patients. Physiother Theor Pract. 2004; 20(3):175-185.

22. Bourdin G, Barbier J, Burle JF, et al. The feasibility of early physical activity in intensive care unit patients: a prospective observational one-center study. Respir Care. 2010;55(4):400-407.

23. Stiller K. Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin. 2007;23:35-53.

24. Portney LG, Watkins MP. Foundations of Clinical Rese-arch: Applications to Practice. 2nd ed. Upper Saddle River, NJ: Prentice Hall; 2000.

25. Korupolu R, Zanni JM, Fan E, et al. Early mobilisation of intensive care unit patient: the challenges of mor-bid obesity and multiorgan failure. BMJ Case Reports. 2010; doi:10.1136/bcr.09.2009.2257.

26. Pasulka PS, Bistrian BR, Benotti PN. The risks of surgery in obese patients. Ann Intern Med. 1986;104:540-546.

27. Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35:139-145.

28. Orfanos P, Ellis E, Johnston C. Effects of deep breath-ing exercise and ambulation on pattern of ventila-tion in post-operative patients. Aust J Physiother. 1999;45(3):173-182.

29. Stiller K. Physiotherapy in intensive care*: Towards an evidence-based practice. Chest. 2000;118:1801-1813.


Physiotherapy in Critical Care in AustraliaSusan Berney, PhD;1 Kimberley Haines, B.HSc (Physiotherapy);1 Linda Denehy, PhD2

1Physiotherapy Department Austin Health Melbourne, Australia2School of Physiotherapy, The University of Melbourne, Australia

Address correspondence to: Susan Berney, PhD, Physiotherapy Department, Level 3 Harold Stokes Building, PO Box 5555, Heidelberg, Australia 3084 ([email protected]).

ABSTRACTA physiotherapist is part of the multidisciplinary team in most intensive care units in Australia. Physiotherapists are primary contact practitioners and use a comprehensive multisystem assessment that includes the respiratory, cardiovascular, neu-rological, and musculoskeletal systems to formulate individ-ualized treatment plans. The traditional focus of treatment has been the respiratory management of both intubated and spontaneously breathing patients. However, the emerging evidence of the longstanding physical impairment suffered by survivors of intensive care has resulted in physiotherapists re-evaluating treatment priorities to include exercise reha-bilitation as a part of standard clinical practice. The goals of respiratory physiotherapy management are to promote se-cretion clearance, maintain or recruit lung volume, optimize oxygenation, and prevent respiratory complications in both the intubated and spontaneously breathing patient. In the in-tubated patient, physiotherapists commonly employ manual and ventilator hyperinflation and positioning as treatment techniques whilst in the spontaneously breathing patients there is an emphasis on mobilization. Physiotherapists pre-dominantly use functional activities for the rehabilitation of the critically ill patient in intensive care. While variability exists between states and centers, Australian physiothera-pists actively treat critically ill patients targeting interventions based upon research evidence and individualized assess-ment. A trend toward more emphasis on exercise rehabilita-tion over respiratory management is evident.

Key Words: physiotherapy, intensive care

INTRODUCTIONA physiotherapist is part of the multidisciplinary team

in most intensive care units in Australia.1,2 They are primary contact practitioners and use a comprehensive multisystem assessment that includes the respiratory, cardiovascular, neurological, and musculoskeletal systems to formulate individualized treatment plans.3 Physiotherapists provide treatment for respiratory complications including the ap-plication of noninvasive ventilation and exercise and reha-bilitation for the prevention and management of intensive care acquired weakness (ICUAW) and deconditioning as-

sociated with immobility.4 Traditionally the management of respiratory complications such as retained pulmonary secretions, atelectasis, and the avoidance of reintubation has been the major focus of physiotherapy treatment for the critically ill patient. However, the emergence of evidence reporting that many survivors of intensive care suffer long standing weakness and functional limitation as a result of their critical illness has caused physiotherapists to re-evalu-ate treatment priorities and include exercise rehabilitation as a part of standard clinical practice.1

A mix of public and private health care providers de-livers health care in Australia. Health care is funded na-tionally under a system called Medicare that covers all Australian citizens although individuals have a choice of opting for additional private health insurance using a pri-vate sector health provider.5 Public hospitals are directly funded by government. Health care that includes access to a bed, medical, nursing, allied health including physio-therapy and ancillary services is provided free of charge. There are a relatively small number of private hospitals with the majority of acute care and emergency beds located in public hospitals. More complex advanced care occurs pre-dominantly in the metropolitan public hospitals, although increasingly, larger private hospitals are providing more complex care including intensive care.5

Intensive care units in Australia are classified from level one to 3 (Table 1) with level 3 being able to provide the most advanced life support services. Units are staffed by Intensive Care Specialists and a mix of junior and more senior medical staff who may be involved in a speciality training program. Nurses may have a tertiary certificate in critical care and are staffed on a 1:1 ratio for ICU beds and 1:2 for high depen-dency beds where patients do not require mechanical venti-lation or renal replacement therapy. The average cost of an ICU bed is $2500-$3000 (AUD) per day and this comprises approximately 20% of hospital expenditure.6

Most intensive care units in Australia have at least one senior physiotherapist on staff and almost half of these physiotherapists have greater than 5 years of critical care experience.1,2 Whilst many have research experience in ICU, few have research higher degrees.1,2 No specific ad-ditional training is required for physiotherapists to work in ICU in Australia. Staffing profile is dependent on the level of the unit based on the intensity of medical care provided, the number of beds, and the availability of physiotherapy staff.7 Physiotherapy services are generally provided each day or part thereof from 0800-1700. A small number of units have the provision for a 24 hour or after hours ser-


vice.7 Most physiotherapists in Australia are able to initiate assessment and treatment without medical and/or nursing referral as part of the multidisciplinary team.2

ROLE OF THE PHySIOTHERAPISTS: RESPIRATORy MANAGEMENT

The goals of respiratory physiotherapy management are to promote secretion clearance, maintain or recruit lung volume, optimize oxygenation and prevent respiratory complications in both the intubated and spontaneously breathing patient.3

The Intubated PatientRespiratory dysfunction in the intubated patient is char-

acterised by the underlying pathology; altered respiratory mechanics due to the effects of positive pressure ventila-tion, ventilation and perfusion mismatch,8 and mucocili-ary dysfunction.9 Patients who are intubated and ventilated are at risk of developing secretion retention due to the dis-turbance of normal secretion clearance, subsequent atel-ectasis and ventilator associated pneumonia.9 Respiratory physiotherapy aims to treat or prevent these sequelae using a number of different techniques.

Manual HyperinflationManual hyperinflation (MHI) has been commonly used

by Australian physiotherapists for the treatment of sputum retention and pulmonary collapse since the early 1970s.10,11 It involves the delivery of larger than baseline tidal volumes to a peak airway pressure of 40 cmH2O to patients who are intubated using a manual resuscitation bag12,13 (Figure 1). The technique is achieved by delivering a slow inspiratory flow, followed by a 2-3 second inspiratory hold and a fast uninterrupted expiratory flow that mimics a forced expira-tion.14 It has been proposed that in order to achieve the cephalad movement of pulmonary secretions that expira-tory flow must exceed inspiratory flow by more than 10%15 and be sufficient to achieve a velocity of greater than 1000 cm/second to move pulmonary secretions. The interpreta-tion and synthesis of results of studies examining the ef-fects of MHI have been limited by differences in definition, dosage, and technique;3,14,18,19 nonetheless, MHI has been consistently shown to improve static pulmonary compli-ance, secretion removal, reduce airways resistance, and recruit pulmonary collapse.10,13,17,20,21,22 The dosage of MHI reported in the literature varies from 6 cycles of 6 breaths16 to 2 cycles of 6 breaths.23

Ventilator HyperinflationThe beneficial effects of MHI can also be achieved by

altering the settings on the patient’s ventilator.13,24 One of the major advantages of performing ventilator hyperinfla-tion (VHI) in comparison to MHI is the maintenance of positive end expiratory pressure, and the reproducibility of the technique.13,24 Recent survey evidence from senior ICU physiotherapists in Australia reported that up to 39% of ICUs use VHI, predominantly as a technique for pulmonary secretion clearance.25 Dennis et al26 reported that VHI was performed in both controlled and spontaneous modes of ventilation by altering ventilatory parameters. In the spon-taneous mode, VHI is achieved by incremental increases in pressure support and in control modes by either altering pressure or volume limits to reach a predetermined target volume or pressure. Australian physiotherapists demon-strate broad agreement about the indications and applica-tion of VHI in clinical practice.25

PositioningThe application of both MHI and VHI is most frequently

and effectively delivered with the patient in a side lying position with the affected lung uppermost.16,25,26 The side lying position results in an increase in lung volume to the

Table 1. Intensive Care Unit Levels in AustraliaLevel Definition

Level 3 Must be capable of providing complex, multisystem life support for an indefinite period; must be a tertiary referral centre for patients in need of intensive care services and have extensive back-up laboratory and clinical service facilities to support the tertiary referral role. Must also be capable of providing mechanical ventilation, extracorporeal renal support services and invasive cardiovascular monitoring for an indefinite period, or care of a similar nature.

Level 2 Must be capable of providing complex, multisystem life support, and be capable of providing mechanical ventilation, extracorporeal renal support services and invasive cardiac monitoring for a period of at least several days, or longer periods in remote areas, or care of a similar nature.

Level 1 Must be capable of providing basic multisystem life support usually for less than 24 hours. Must also be capable of providing mechanical ventilation and simple invasive cardiac monitoring for a period of at least several hours, or care of a similar nature.

Figure 1. Physiotherapist performing manual hyperinflation.


uppermost lung that enhances recruitment and facilitates drainage from broncho-pulmonary segments and depend-ing on lung pathology, may improve gas exchange.27 Regu-lar turning into the side lying position has also been associ-ated with a reduction in the incidence of ventilator associ-ated pneumonia (VAP) provided that greater than 40° of lateral turn is achieved.28

The addition of a side lying position has been shown to significantly increase sputum yield compared to the su-pine position when using MHI.26 Adding a head down tilt in side lying has been reported to increase sputum clear-ance by up to 25% in our cross-over study of 20 patients who were intubated and ventilated.16 Although there was wide variation, the addition of a head down tilt did not reduce peak expiratory flow which is important if we ac-cept the theory that sufficient expiratory flow is required to achieve movement of pulmonary secretions in the airways. We were able to demonstrate, using an inspiratory flow ob-tained in a similar group of patients that the expiratory flow produced during MHI in both the side lying and head down tilt positions was at least 10% higher than inspiratory flow and sufficient to produce velocities in excess of 1000 cm/sec.16 We therefore contend that if secretion clearance is the primary aim of treatment that a head down tilt should be used provided no contraindications are present.

Manual TechniquesThe extent and use of manual techniques by physiother-

apists in ICU in Australia was last reported 10 years ago.7 At this time both chest wall percussion and vibration were used by up to 80% of physiotherapists, often in combina-tion with MHI.11,21 Since this time, there has been a relative exponential increase in the research output and application of MHI and VHI in clinical practice in Australia and the use of manual techniques has not been reported recently.

Most research into the effectiveness of manual physio-therapy techniques has been undertaken in medical patient populations with excessive secretion production.29 The efficacy of chest wall percussion has not been investigat-ed in an Australian critical care population. In contrast, chest wall vibration in ICU has been investigated by two Australian physiotherapists.21,30 This technique involves the production of large and small oscillatory movements performed during expiration that aim to increase expira-tory flow and subsequent pulmonary secretion clearance.29 Stiller et al21reported that the addition of vibrations to MHI did not further enhance the resolution of atelectasis and Ntoumenopoulos et al31found that chest wall vibration in combination with positioning was associated with a reduc-tion in rates of VAP by 27%.

SuctioningTracheal suctioning is used during a physiotherapy

treatment to clear pulmonary secretions.8 It has been asso-ciated with episodic hypoxemia and cardiac arrhythmias31 that may have previously been attributed to the effects of the physiotherapy treatment.32,33 The metabolic effects of a physiotherapy treatment that included VHI, side lying and

endotracheal suctioning reported that the greatest increases in oxygen consumption were recorded during and follow-ing the suctioning procedure.34 Whilst the instillation of saline prior to suction remains controversial,35 it is used selectively in clinical practice to assist in the clearance of tenacious pulmonary secretions.

Efficacy and SafetyMultimodal respiratory physiotherapy treatment as

practiced by Australian physiotherapists has been shown to be safe with a prospective audit of 5 metropolitan tertiary hospitals reporting only 29 adverse physiological events occurring in 12,800 treatments (0.22%).36 In addition the metabolic demands of physiotherapy treatment are no greater than turning a patient into a side lying position.34

The efficacy of prophylactic multimodal physiotherapy treatment used in Australian ICUs in trauma populations has been evaluated against various clinical endpoints with conflicting results.23,30,37 The addition of MHI in a side ly-ing position to standard nursing and medical care has shown no significant reduction in the incidence of VAP, the duration of mechanical ventilation or ICU length of stay.23,37 Conversely in a heterogeneous population, the addition of chest wall vibrations in a side lying position was associated with a 27% reduction in VAP, although no differences in the duration of mechanical ventilation and ICU length of stay were observed.30 Differences in outcomes can be explained by the different populations and the limited sample sizes of the two studies examining MHI. Nonetheless, these studies, in combination with the emerging evidence to support the role of rehabilitation in critically ill patients, have resulted in respiratory treatment being reserved for patients presenting with atelectasis and pulmonary secretion retention rather than as routine or prophylactic intervention.

The Non-intubated PatientDespite not requiring intubation or ventilation, patients

often require intensive physiotherapy treatment in the ICU. Patients may be at risk of developing respiratory failure fol-lowing extubation, admitted for routine postoperative sur-veillance, require treatment for postoperative pulmonary complications, or present with hypercapnic or hypoxemic respiratory failure requiring noninvasive ventilatory support.

In the postoperative setting physiotherapists aim to increase lung volume using mobilization, periodic appli-cation of noninvasive ventilation (NIV), and on occasion, deep breathing exercises.3 However, recent evidence sug-gests that routine respiratory physiotherapy in addition to mobilization may be of no added benefit in reducing postoperative pulmonary complications following major cardiac and upper abdominal surgery.38-40 In an Australian setting, a small study of 56 patients suggested that mobili-zation can reduce the incidence of pulmonary complica-tions39 although the dose, frequency, and intensity have not been established. A small observational study of 50 patients reported that the time spent upright was less than 10 min-utes in the first two postoperative days.41 The majority of


mobilization in the postoperative setting in Australia is per-formed by physiotherapists.41

Although the use of continuous NIV for the treatment of hypercapnic respiratory failure and cardiogenic pulmonary edema is supported by high level evidence,42,43the delin-eation of roles regarding clinical decision making and ap-plication of the apparatus between nursing, medicine, and physiotherapy varies greatly in Australia. This is potentially dependent on the availability of physiotherapy services, the experience of clinicians and their seniority in the ICU.

The application of periodic continuous positive airways pressure (pCPAP) is used by Australian physiotherapists for the prevention and treatment of pulmonary complications such as atelectasis. The implementation and supervision of pCPAP is reported to be a shared responsibility between critical care nurses and physiotherapists.7 The dosage and interface used for the application for pCPAP by physiother-apists in the critical care setting is most likely dependent on the severity of respiratory failure, local unit policies, and equipment availability, although this has never been inves-tigated.

REHABILITATION AND MOBILIZATIONThe progress of intensive care medicine has resulted

in significant improvements in survival rates.44,45 Approxi-mately 119,000 patients require admission to a general ICU in Australia each year with survival rates around 89% at hospital discharge.46 However, the legacy of ICU sur-vival can be significant with prolonged immobility and ca-tabolism resulting in deconditioning, muscle atrophy, and weakness that may impact future health-related quality of life.47 Reports of long-standing weakness, impaired physi-cal function,48-50 and institutional changes to sedation and delirium management of the critically ill51-53 have resulted in increased interest in the provision of early rehabilitation to patients in the ICU. The benefits and safety of rehabili-tation performed in the ICU have been reported in the US and European literature.54-56 However, to date, there is a lack of evidence in the Australian setting. Currently in Aus-tralia at least 5 studies are being conducted or have been recently completed examining the outcomes of ICU sur-vivors, the efficacy of rehabilitation on physical function and health related quality of life, and the effects of critical illness on muscle.

In Australia many different activities are defined by the term mobilization. These include sitting on the edge of the bed and out of bed, marching on the spot, and walking away from the bed.1 These activities reflect specificity of training for functional tasks essential for independence at hospital discharge.3 Level 3 and 4 evidence from the US has reported that walking intubated and ventilated patients has reduced ICU and hospital length of stay and hospital readmission at 12 months.57,58 The pattern and dosage of mobilization that includes walking away from the bed in patients who are intubated in Australian ICUs is unknown but is an area of current investigation.

Interventions used by Australian physiotherapists aimed at maintaining muscle strength, joint range, and function

have been established using 3 surveys.1,2,59 The most com-prehensive of these was carried out by Skinner et al.1 This group surveyed predominantly senior physiotherapists from 126 Australian ICUs and reported that 94% of therapists prescribe exercise routinely for long stay ICU patients.1 In patients who were intubated and ventilated, the number of therapists who prescribe exercise is reduced to just over 70%. Irrespective of ventilatory status, active assisted or free active exercise was most commonly prescribed al-though the method to achieve this activity was varied. The main difference in approach to rehabilitation for patients who were intubated and ventilated was that mobilization away from the bed was less common with only 55% of respondents nominating it as a rehabilitation intervention compared to over 90% for patients who were spontane-ously breathing.

Adjuncts to treatment that assist the movement of pa-tients into an upright position such as a tilt table were not frequently used by physiotherapists.1,59 These surveys re-ported that whilst the tilt table was considered an option for rehabilitation, physiotherapists preferred to use assisted standing or marching rating the tilt table the least preferred exercise activity1 potentially used less than once per month or once per year.59

Historically passive limb movements have been used by physiotherapists to maintain joint range and prevent soft tissue contracture.4 However, recent evidence suggests that Australian physiotherapists do not routinely prescribe passive limb movements for the critically ill.2 In a survey of predominantly senior physiotherapists from 51 ICUs only one third routinely assessed joint range of movement and 14% of respondents used passive range of movement exercises. This number of responses may reflect the lack of evidence to support the technique.4 Assessment of joint range of motion was reserved for patients in whom there was a high degree of suspicion that range may be limited such as burns, pre-existing contracture or the presence of increased tone.2

Evidence for the use of newer modalities by Australian physiotherapists to assist rehabilitation such as cycle er-gometry and neuromuscular electrical stimulation has not been established. Neuromuscular electrical stimulation has been widely established within the healthy population to prevent muscle atrophy and minimize muscle protein breakdown by improving oxidative metabolism.60 It has been used with good effect in chronic inflammatory dis-eases, such as chronic heart failure and chronic obstructive pulmonary diseases improving quadriceps strength, physi-cal function, and health-related quality of life. There have been 4 primary studies to date investigating neuromuscu-lar electrical stimulation in the ICU population with con-flicting results of effectiveness.61-64 Cycle ergometry can be used passively or actively. A recent randomised controlled trial examined the effect of cycle ergometry in critically ill patients and reported improvements in quadriceps strength and physical function at acute hospital discharge.54 How-ever the intervention did not begin until two weeks postad-mission and there were no data reporting frequency of ac-


tive versus passive cycling. It is currently unknown whether passive cycling has any impact on muscle characteristics. Both neuromuscular electrical stimulation and cycle er-gometry are currently being evaluated in prospective ran-domised trials in Australian ICUs. The results of these trials will influence future uptake of these and other rehabilita-tion interventions.

Outcome MeasurementA major finding of the survey of Skinner and col-

leagues1 was a lack of consistent outcome measurement by physiotherapists to evaluate the effects of their exercise intervention. Whilst the majority of physiotherapists pre-scribed exercise routinely for patients in ICU, only one third of therapists used any form of outcome measure for exercise prescription, progression, or assessment of overall efficacy. Outcomes that were monitored for safety and ex-ercise modification were heart rate and oxygen saturation.1

Since the results of Skinner and colleagues1 were pub-lished, the Physical Function in ICU Test (PFIT) has been reported.65 This multidimensional test of function, strength, and endurance has been shown to be reliable and sensitive to change and has recently been scored. The PFIT has been incorporated into the protocol of one international and 3 Australian trials evaluating the effects of rehabilitation on functional outcome for critically ill patients. The clinomet-ric properties of the test, including scoring, have been pre-sented and are published in abstract form.66

Whilst the PFIT was designed specifically for an ICU population, other tests of physical function have been used to assess the functional outcome of survivors of ICU such as the Acute Care Index of Function (ACIF), the Six Minute Walk Test, the Barthel Index, the Functional Independence Measure (FIM), and the Glittre Activities of Daily Living Test.67 Both the FIM, using a sub-set of activities suitable for an ICU population68 and the ACIF have been reported in the ICU cohort; however, the remaining tests were devel-oped for other medical specialities such as rehabilitation or aged care and logistically are not suitable to be used in the ICU setting for the prescription and evaluation of exercise.

Safety and FeasibilityThere have been several international reports of the

safety and feasibility of mobilizing patients away from the bed side who are intubated and ventilated.57,69,70 In an Australian setting there has been one report of the safety of mobilizing patients using specific safety criteria for ini-tiation and progression of treatment.71 These investigators developed a guideline based on a comprehensive patient assessment that included the cardiovascular and respiratory status as well as clinical reasoning to determine readiness for mobilization. They subsequently prospectively evalu-ated the utility of the physiological criteria of the guideline on 31 patients who performed 69 mobilization tasks that included sitting on the edge of the bed, transferring out of bed, and mobilizing on the spot and away from the bed.71 Only on three occasions (4.3%) did a patient demonstrate clinical deterioration that required transient intervention

and on no occasion was the mobilization treatment ceased. The guideline demonstrated good clinical utility and pro-vides the only systematic approach to patient assessment of readiness for mobilization although its use in clinical prac-tice has not been reported in Australia.

The safety and feasibility of a hierarchical protocolized exercise rehabilitation program has been reported by this author in an Australian setting.72 As part of a larger ran-domised controlled trial, rehabilitation that included car-diovascular, strength and functional training was intro-duced on day 5 of the ICU stay; the intensity of which was based on the results of the PFIT. These tasks were included as they reflected Australian practice.1 Patients completed 15 minutes of exercise twice daily in the ICU with exer-cise progression based on Borg scores and the PFIT. Strict safety criteria for the initiation and cessation of exercise were used and no adverse events were recorded in 641 rehabilitation sessions. These results and those of Stiller and colleagues71 reflect the increasing interest in the role of mobilization and rehabilitation for critically ill patients.

FutureMandated guidelines for the management of deteriorat-

ing patients in Australian public hospitals73 have resulted in opportunities for physiotherapists to become increas-ingly involved in critical outreach teams. A multisystem assessment and the frequent requirement for noninvasive ventilatory support suit the skill mix of physiotherapists ex-perienced in the care of the critically ill. This expansion of the conventional physiotherapy role may require additional education and acquisition of specific task related and diag-nostic skills.

A commitment to research is essential for the growth of physiotherapy in the critical care area particularly in the role of exercise and rehabilitation. The benefits of rehabili-tation for survivors of ICU in both in the short- and long-term require elucidation in randomized controlled trials. Rehabilitation should take into consideration the cognitive as well as physical function of the patients. Epidemiologi-cal studies to determine patients at risk for the develop-ment of longer term weakness and strategies to attenuate and treat weakness and impaired physical function are a priority. Further development of outcome measures that are sensitive and valid and specifically designed for critically ill patients are also necessary. The economic impact of ICU-acquired weakness and its treatment should be assessed in all future trials.

CONCLUSIONSThis paper describes the role of physiotherapists in criti-

cal care in Australia. While variability exists between states and centers, as primary care practitioners, Australian phys-iotherapists actively treat critically ill patients targeting inter-ventions based upon research evidence and individualized assessment. A trend toward more emphasis on research into exercise rehabilitation over respiratory management is now evident. The outcomes of this developing evidence base will shape the direction of future roles of physiotherapists


in the ICU and in follow up of ICU patients. It is important that physiotherapists lead this research, formulating ques-tions that are based upon their extensive understanding of physical function and its importance to activities of daily living and health related quality of life.

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What Are the Barriers to Mobilizing Intensive Care Patients?

I Anne Leditschke, FRACP, FCIC, MMgt;1 Margot Green, Bachelor of Applied Science (Physiotherapy); 2 Joelie Irvine, BPhysio;3 Bernie Bissett, Bachelor of Applied Science (Physiotherapy) (Hons); 4 Imogen A. Mitchell, FRCP FRACP FCICM5

1Senior Specialist, Intensive Care Unit, Canberra Hospital; & Senior Lecturer, Australian National University, Canberra, Australia, 2Senior Physiotherapist, Intensive Care Unit, Canberra Hospital; & Physiotherapy Department, Canberra Hospital, Canberra, Australia, 3Cardiorespiratory Physiotherapist, Physiotherapy Department, Canberra Hospital, Canberra, Australia

4Clinical Educator, Physiotherapy Department, Canberra Hospital; & University of Queensland, Australia, 5Director, Intensive Care Unit, Canberra Hospital; and Associate Professor, Australian National University, Canberra Australia

Address correspondence to: I Anne Leditschke, FRACP, FCICM, MMgt, Intensive Care Unit, Canberra Hospital, Canberra, ACT Australia 2605, Ph: +61 2 6244 3103, Fax: +61 2 6244 3507 ([email protected]).

ABSTRACTPurpose: Recently there has been increased interest in early mobilization of critically ill patients. Proposed benefits in-clude improvements in respiratory function, muscle wast-ing, intensive care unit (ICU), and hospital length of stay. We studied the frequency of early mobilization in our inten-sive care unit in order to identify barriers to early mobiliza-tion. Methods: A 4-week prospective audit of 106 patients admitted to a mixed medical-surgical tertiary ICU (mean age 60 ± 20 years, mean APACHE II score 14.7 ± 7.8) was performed. Outcome measures included number of patient days mobilized, type of mobilization, adverse events, and reasons for inability to mobilize. Results: Patients were mo-bilized on 176 (54%) of 327 patient days. Adverse events occurred in 2 of 176 mobilization episodes (1.1%). In 71 (47%) of the 151 patient days where mobilization did not occur, potentially avoidable factors were identified, includ-ing vascular access devices sited in the femoral region, tim-ing of procedures and agitation or reduced level of con-sciousness. Conclusions: Critically ill patients can be safe-ly mobilized for much of their ICU stay. Interventions that may allow more patients to mobilize include: changing the site of vascular catheters, careful scheduling of procedures, and improved sedation management.

Key Words: intensive care units, mobility, physical therapy

INTRODUCTION AND PURPOSEIn many intensive care units, it has been usual practice

to manage critically ill patients with deep sedation and bed rest.1 However, an increasing body of literature has docu-mented the complications associated with bed rest, which affect virtually every body system.2-5 Much recent attention has focused on intensive care unit (ICU)-acquired weakness

and the long-term adverse functional sequelae for ICU sur-vivors, particularly in the physical domain6,7 and this has led to an increased interest in early mobilization in the ICU as a potential means of prevention. Proposed potential ben-efits of early mobilization of critically ill patients include improvements in respiratory function, reduced muscle wast-ing, decreased ICU and hospital length of stay, and reduced readmission and mortality for 12 months postdischarge.8-11

We have been pursuing a strategy of reduced sedation and active mobilization in our ICU for approximately 10 years.12 Unless deep sedation is required for a clear medi-cal indication, such as the management of intracranial hypertension following traumatic brain injury, sedation in our ICU is managed with a nurse-controlled sedation al-gorithm, titrated to a goal Riker Sedation Agitation Scale13 of 4, which is a calm, alert, and cooperative patient. Anal-gesia is managed with patient-controlled analgesia where possible, and nurse controlled analgesia when this is not possible. In order to assess the frequency of early mobiliza-tion in our ICU and to identify barriers to early mobiliza-tion, we performed a quality audit.

METHODSParticipants

A 4 week prospective audit of usual practice was con-ducted on all 106 patients present in a mixed medical-surgi-cal tertiary ICU during a 4 week period in October-November 2008. Mean age was 60 (SD 20) years, and mean APACHE II score14 was14.7 (SD 7.8). Of the 106 patients admitted, 70 (66%) were male, with surgical postoperative admissions in 47 patients (44%) and trauma admissions in 14 patients (13%). Median ICU length of stay was one (range 1-198) day, and median hospital length of stay was 12.5 (range 1-454) days. The study was approved by the relevant Canberra Hos-pital Executive as a quality audit and has been approved by the Australian Capital Territory Human Research Ethics Com-mittee as a Low Risk Study (ETHLR.11.225).

Mobilization techniquesThe mobilization techniques used were classified into

3 groups:


1. Active mobilization was defined as marching on the spot for > 30 seconds or mobilizing away from the bed-space (Figure 1A).

2. Active transfer was defined as active transfer from bed to chair where the patient assists with transfer against gravity (Figure 1B).

3. Passive transfer, where a lifter, sling, or other device is used to transfer a patient out of bed, with minimal patient assistance with the transfer (Figure 1C).

Data collectionDe-identified data were collected on the number of pa-

tient days mobilized, type of mobilization, adverse events, and reasons for inability to mobilize as follows. For each day during the audit period, the physiotherapist assigned to the ICU on that day recorded the number of patients in the ICU on that day. For each patient for that day, whether they were mobilized and the type of mobilization, any adverse events and reasons for inability to mobilize was also recorded. If there were multiple reasons for inability to mobilize in a sin-gle patient, a judgement was made about the most important reason for not mobilizing. For example, a patient who was hemodynamically unstable and was medically required to rest in bed because of a fractured pelvis would be classified as unable to mobilize due to medical orders.

Additional data collected by the physiotherapist pro-spectively included demographic data (age and gender) and admission diagnosis. This was compared for accuracy with the de-identified data routinely collected for quality purposes as part of our contribution to the Australian and New Zealand Intensive Care Society (ANZICS) Adult Pa-tient Database15. Severity of illness (APACHE II14) scoring for the audit period was obtained from the de-identified data routinely collected for quality purposes as part of our contribution to the database, and was calculated using AN-ZICS AORTIC software, version 7.0.16

Outcome MeasuresA patient day was counted for each day that a patient

was in the ICU during the audit. For each patient day, type of mobilization, adverse events, and reasons for inability to mobilize were recorded.

RESULTSFrequency of mobilization

There were 327 patient days during the audit period. Ventilated patient days accounted for 155 (47%) of these. Although 47 (44%) of the 106 patients present in the ICU unit during the audit period were postoperative surgical pa-tients, only 54 (17%) of the 327 patient days audited were postoperative patient days, presumably because these pa-tients had shorter ICU length of stay.

Patients were mobilized on 176 (54%) of the 327 patient days audited. Figure 2 demonstrates the propor-tions of different types of mobilization that occurred, and the impact of mechanical ventilation on mobiliza-tion overall and mobilization techniques used. Active mobilization occurred in 76 patient days (23%) and active transfer in 40 patient days (12%). Of these 116 patient days, 20 (17%) involved patients who were me-chanically ventilated. Passive transfer was the mobiliza-tion method used for 60 patient days and 40 (67%) of these passive transfer days involved mechanically venti-lated patients. Of the 106 patients in the audited period, 11 (10%) underwent passive transfer, 28 (26%) active transfer, 36 (34%) active mobilization, and 31 (29%) re-mained resting in bed.

Adverse eventsThere were two adverse events recorded in 176 mo-

bilization episodes (1.1%). Both episodes involved hypo-tension requiring intervention (return to bed, fluid loading, and transient increase in vasopressor requirements).

Figure 1. Mobilization methods. A. Active mobilization (left frame). B. Active transfer (middle frame). C. Passive transfer (right frame).

A B C


Barriers to mobilizationFigure 3 is a frequency histogram of the reasons that

patients were not mobilized, for both ventilated and non-ventilated patient days. Reasons for inability to mobilize in-cluded potentially avoidable factors in 47% of the patient days surveyed. These included vascular access catheters in a femoral position in 32 patient days, timing of procedures in 18 patient days, sedation management in 12 patient days (agitation in 9 patient days and low Glasgow Coma Score in 3 patient days) and early ward transfer in 9 patient days. Of the unavoidable factors preventing mobilization, respiratory instability was the most frequent, accounting for 20 patient days, followed by hemodynamic instability for 17 patient days, neurologic instability (difficult to control intracranial hypertension) for 15 patient days, and medical orders to rest in bed (for pelvic fractures or similar indication)15 patient days. Other unavoidable factors occurred in13 patient days.

DISCUSSIONWe undertook this audit to assess our performance in

mobilizing patients and to record reasons patients were not mobilized in an attempt to identify modifiable factors. We were surprised that only 54% of patient days involved mobilization, as we expected the proportion of mobilized patient days to be higher than this, but these results are consistent with the critical care nutrition literature, where underfeeding, despite a perception of adequate feeding, is common.17 This is also consistent with physiotherapy evi-dence regarding mobilization of postoperative abdominal surgery patients, where amount of time out of bed was found to be low18 despite evidence that early physiotherapy reduces postoperative pulmonary complications.19 Howev-er our mobilization rate compares favorably to the two re-cent prospective randomized controlled trials of early mo-bilization in critically ill patients, in which fewer than 10% of screened patients were enrolled.8,9 Although both stud-ies suggested that mobilization therapy was beneficial, the low enrollment to screening ratio casts some doubt on the generalizability of these results to the critical care patient population. The very low occurrence of adverse events in our study is consistent with other published studies, which have reported no adverse events or adverse event rates of less than 1%.8-10,20-22 Specifically, we were able to mobilize ventilated patients with both passive and active mobiliza-tion techniques, and find it surprising that anecdotally some ICUs are still reluctant to mobilize these patient groups de-spite the low risks20,21 and potential benefits.

It is of note that in almost half of the patient days where mobilization did not occur, mobilization would have been possible with relatively simple changes in management, such as selection of site for vascular access devices, timing of procedures and improved sedation management. As early mobilization has been shown to be the key component of physiotherapy intervention for reducing postoperative pul-monary complications in high risk patients23 and recent evi-dence suggests that a critical care early mobilization program reduces the risk of death or hospital readmission within 12

Figure 2. Mobilization methods and ventilation status.Top: Relative frequencies of each mobilization method. Patients were mobilized out of bed via passive transfer, active transfer, or active mobilization. Patients not mobilized remained in bed.

Figure 3. Frequency of barriers to mobilizationThe number of patient days that patients were not mobilized is shown for each categeory of reason for non-mobilization both ventilated and nonventilated patient days with the frequency of each reason recorded. GCS: Glasgow Coma Score.


months of discharge,11 it would seem imperative that all re-versible obstacles to early mobilization should be addressed. While the most effective method of implementing an early mobilization program in the ICU is yet to be determined, we believe that a multidisciplinary team approach including ac-tive collaboration between physiotherapy, nursing and medi-cal staff is likely to be the most effective. Whatever model is used, active identification of barriers to mobilization and active planning to avoid these issues should be included as part of the mobilization strategy.

CONCLUSIONSIn summary, we have demonstrated that in our intensive

care unit patients are mobilized more than 50% of patient days, and that this high frequency of mobilization is safe. In addition, we have identified a number of relatively simple interventions that may allow more patients to mobilize, in-clude changing the site of vascular access devices, careful scheduling of procedures, and improved sedation manage-ment. Further studies investigating the impact of strategies to address these issues are recommended.

REFERENCES1. Needham DM. Mobilizing patients in the intensive

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6. Herridge MS. Building consensus on ICU-acquired weakness. Intensive Care Med. 2009;35:1-3.

7. Cuthbertson BH, Roughton S, Jenkinson D, Maclennan G, Vale L. Quality of life in the five years after intensive care: a cohort study. Crit Care. 2010;14:R6.

8. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechani-cally ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373:1874-1882.

9. Burtin C, Clerckx B, Robbeets C, et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med. 2009;37:2499-2505.

10. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute re-spiratory failure. Crit Care Med. 2008;36:2238-2243.

11. Morris PE, Griffin L, Berry M, et al. Receiving early mobility during an intensive care unit admission is a

predictor of improved outcomes in acute respiratory failure. Am J Med Sci. 2011; 34:373-377.

12. Feeley K, Gardner A, Mitchell I, Leditschke A. Does implementation of a goal sedation score improve man-agement of mechanically ventilated adults? Crit Care. 2005,9(Suppl 1):P141.

13. Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med. 1999; 27:1325-1329.

14. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med.1985;13:818–829.

15. Stow PJ, Hart GK, Higlett T, et al. Development and implementation of a high-quality clinical database: the Australian and New Zealand Intensive Care Society Adult Patient Database. J Crit Care. 2006;21:133-141.

16. AORTIC software. http://www.anzics.com.au/core/aor-tic-software. Accessed October 17, 2011.

17. Martin CM, Doig GS, Heyland DK, et al. Multicen-tre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). CMAJ. 2004;170:197-204.

18. Browning L, Denehy L, Scholes RL. The quantity of early upright mobilisation performed after upper ab-dominal surgery is low: an observational study. Aust J Physiother.2007;53:47–52.

19. Chumillas S, Ponce JL, Delgado F, Viciano V, Mateu M. Prevention of postoperative pulmonary complications through respiratory rehabilitation: A controlled clinical study. Arch Phys Med Rehabil. 1998;79:5–9.

20. Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35:139-145.

21. Pohlman MC, Schweickert WD, Pohlman AS, et al. Fea-sibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med. 2010;38:2089-2094.

22. Zeppos L, Patman S, Berney S, Adsett JA, Bridson JM, Paratz JD. Physiotherapy in intensive care is safe: an observational study. Aust J Physiother. 2007;53:279-283.

23. Mackay MR, Ellis E, Johnston C. Randomised clinical trial of physiotherapy after open abdominal surgery in high risk patients. Aust J Physiother.2005;51:151–159.


Physical Therapy Management of a Patient on Portable Extracorporeal Membrane Oxygenation

as a Bridge to Lung Transplantation: A Case ReportJohn D. Lowman, PT, PhD, CCS;1 Tamara K. Kirk, PT, CCS;2 Diane E. Clark, PT, DScPT, MBA1

1University of Alabama at Birmingham, Department of Physical Therapy, Birmingham, AL2Duke University Hospital, Department of Physical and Occupational Therapy, Durham, NC

Address correspondence to: John D. Lowman, PT, PhD, CCS, University of Alabama at Birmingham, De-partment of Physical Therapy, 344 School of Health Professions Building, 1530 3rd Avenue South, Birming-ham, AL 35294 ([email protected]).

ABSTRACTIntroduction: Although the life expectancy for patients with cystic fibrosis (CF) has increased dramatically in the preced-ing decades, often the final therapeutic option for patients with end-stage CF is lung transplantation. Prior to transplan-tation, patients with severe disease may require mechanical ventilation. Those refractory to mechanical ventilation may require extracorporeal membrane oxygenation (ECMO). The purpose of this case report is to describe the physical therapy management of a patient who received ECMO as a bridge to lung transplantation. Case Presentation: A 16-year-old girl with severe acute respiratory failure due to a CF exacer-bation eventually required ECMO to maintain adequate gas exchange. While on ECMO, she received physical therapy interventions ranging from therapeutic exercise, manual therapy, and integumentary protection techniques in addi-tion to airway clearance techniques. Prior to her transplant, she was standing multiple times per day with moderate as-sistance, was sitting on the edge-of-bed, as well as taking steps to transfer to/from a chair. She successfully received a bilateral lung transplant after 8 days on ECMO. Conclusion: Physical therapy interventions, including out-of-bed mobil-ity, can be safely provided to patients on portable ECMO as a bridge to lung transplantation. These interventions were focused on preventing the negative sequelae of bed rest, in-creasing her strength and endurance, as well as improving her level of consciousness and psychological well being in preparation for lung transplantation.

Key Words: extracorporeal membrane oxygenation, lung transplantation, physical therapy, exercise

BACKGROUND AND PURPOSECystic fibrosis (CF) is no longer a disease of children;

projected life expectancy for patients with CF has increased

into the late 30s, and continues to grow. The genetic defect, affecting the cystic-fibrosis transmembrane conductance regulator (CFTR), leads to mucosal obstruction in multiple tissues, especially the lung. Associated lung pathology is the primary contributor to mortality in patients with CF.1 Treatment of the pulmonary involvement typically includes inhaled medications [eg, hypertonic saline, tobramycin (an antibiotic), and dornase alfa (a mucolytic)], systemic antibi-otics, airway clearance, and exercise.2 As the disease pro-gresses, pulmonary exacerbations become more frequent and severe and are associated with increased morbidity and mortality.3 Although there are many new exciting ther-apies for CF in the pipeline,1,2 for patients with frequent exacerbations and severe disease, lung transplantation is often the final therapeutic option.2

Cystic fibrosis is the third leading indication for lung transplantation.4 Although transplantation of patients on me-chanical ventilation was previously discouraged, the current US lung allocation system assigns high scores to ventilator-dependent patients, since they have a high “medical urgen-cy.”4 Patients with CF who undergo lung transplantation have similar outcomes whether they are mechanically ventilated or nonmechanically ventilated at the time of transplanta-tion.5 Another potentially controversial group for lung trans-plantation are patients requiring preoperative extracorporeal membrane oxygenation (ECMO).4 Although the early post-operative risk of death is almost 2.6 times higher in patients requiring ECMO prior to lung transplant compared to the un-supported patient, survival after 9 months is fairly similar.6

Extracorporeal membrane oxygenation is used to main-tain adequate gas exchange in patients with severe respira-tory failure that is refractory to even maximal mechanical ventilatory support, including patients who are waiting for a lung transplant. Most patients on ECMO are sedated and on bed rest, but there are a few reports of ambulatory pa-tients on ECMO as a bridge to lung transplantation.7,8 If ECMO is to be a successful bridge to lung transplantation, then prevention of the many sequelae of bed rest and a continuation of pretransplant rehabilitation is needed. The purpose of this case report is to describe the physical therapy management of a patient who received ECMO as a bridge to lung transplantation. Consent of the patient and permission of her family were provided to present the case.


CASE DESCRIPTION “Jane,” a 16-year-old female with CF, was admitted to

a tertiary-care children’s hospital for worsening shortness of breath. Over the next week, her condition continued to deteriorate until she eventually went into severe respiratory failure, requiring mechanical ventilation. The following day Jane was transferred to the pediatric intensive care unit (PICU) at our hospital for management of her respiratory failure and evaluation for lung transplantation (hospital day [HD) 0]. On admission, her respiratory failure was refrac-tory to traditional mechanical ventilation (see Table 1), and required that she be placed on a high-frequency percus-sive ventilator [(The Percussionaire® VDR®-4) with peak inspiratory pressure 30 cm H2O, frequency 510 cycles/min, inspiratory time 3.0 sec, positive end expiratory pressure (PEEP) 10 cm H20, FiO2 1.00]. The high-frequency percus-sive ventilation improved her hypercapnia and acid-base balance, but did little for her oxygenation (Table 1).

Cardiovascular and pulmonary examination revealed mild sinus tachycardia (90-110 bpm) of normal rhythm (per EKG) and a blood pressure ranging from 90-125/64-74 mm Hg (per arterial BP monitor); her respiratory frequency was ventilator dependent (as noted above) and SpO2 ranged from 95% to 97%. The high-frequency percussive venti-lator precluded performance of a valid chest examination due to the excessive noise and vibration from the ventilator. She also had severe digital clubbing and 4+ pitting edema in her right foot. Her skin was dry, but intact and without evidence of excessive pressure.

Shoulder flexion and abduction were limited bilaterally to ~150° and 120°, respectively; otherwise, her upper ex-tremity range of motion (ROM) was normal. Lower extrem-ity ROM and flexibility were normal with the exception of ankle dorsiflexion to neutral with her knees extended. Muscle bulk was quite diminished. She was hypotonic but demonstrated right greater than left ankle clonus.

Table 1. Arterial Blood Gas Values Hospital day FiO2 pH pCO2

(mm Hg)pO2

(mm Hg)HCO3

(mmol/L)SaO2

(%)PaO2/FiO2

0 1.00 7.09 187 63 54 87.8 63

High-frequency jet ventilation initiated

1 0.85 7.30 102 63 49 91.3 74

5 0.70 7.28 94 68 42 93.1 97

ECMO initiated

7 0.45 7.56 40 42 35 86.3 93

9 0.35 7.46 49 83 35 96.3 237

11 0.35 7.47 51 77 36 95.7 220

14 0.35 7.40 57 70 34 91.9 200

Bilateral lung transplant

16 0.21 7.55 32 91 28 94.8 433

19 0.21 7.54 37 75 32 93.8 357

Past Medical HistoryOver the course of the past year, Jane had repeated lung

infections requiring repeated intravenous (IV) antibiotics. Her last exacerbation was 3 months prior to this episode. Jane was also pancreatic insufficient and had lost approxi-mately 14 kg (30 lbs) over the last several months. Her family reported that she had been active and fairly athletic until her recent exacerbations.

Physical Examination (Hospital Day 6)Physical therapy was consulted on HD 6, while Jane

was in the PICU sedated and nonresponsive. On obser-vation, she was on mechanical ventilation via oral en-dotracheal tube, and connected to a left radial arterial line, left brachial double-lumen peripheral-inserted cen-tral catheter, two right peripheral intravenous catheters, naso-gastric tube, Foley catheter, pulse oximeter, and ECG monitor. Her body mass and height were 38 kg (84 lbs) and 152.5 cm (5’0”) respectively, giving her a BMI of 16.3 kg/m2.

Clinical ImpressionJane was severely hypercapnic, requiring high levels of

mechanical ventilation, high FiO2, and medical sedation. Given her current medical status, we did not address any activity goals at this time. Rather, we focused our goals on preventing anticipated problems9 associated with bed rest and immobility such as joint contractures at the shoulder, elbow, hip, knee, and ankle that can limit activity and of-ten persist through discharge from the hospital.10 Pressure sores also frequently occur in the ICU. Underweight pa-tients, like Jane, have a 5-fold greater risk for developing pressure sores primarily at the sacrum and heel.11,12

Interventions (HD 6)Initial interventions included passive range of motion

(PROM) to all major upper and lower extremity joints, stretch-ing of plantar flexors, and application of pressure relieving ankle foot orthoses (PRAFO®) to maintain the feet in neutral dorsiflexion, hip in neutral rotation, and keep her heels el-evated off the bed (Table 2). Airway clearance was not a PT


intervention as respiratory therapy administered intrapulmo-nary percussive ventilator treatments every 4 hours.13

Re-examination (HD 7)Despite high FiO2 and high-frequency percussive ventila-

tion, Jane remained significantly hypoxic and hypercapnic (see Table 1) resulting in her placement on veno-venous ECMO via double lumen cannulation of the right internal jugular vein, as well as placement on the lung transplantation list (HD 6). On the morning of HD 7, she received a tracheostomy and was converted to synchronized intermittent mechanical ventila-tion (tidal volume 4.2 ml/kg, frequency 16 breaths/min, PEEP 10 cm H2O, FiO2 0.45) with much improved gas exchange (see Table 1). She remained medically sedated.

Interventions (HD 7-8)Jane’s physicians were consulted regarding her ability to

participate in physical therapy now that she was on ECMO. Given that Jane’s pulmonary status was stabilized, the phy-sicians planned to decrease her sedation to allow her to progress to active exercise and begin mobility training. Jane’s right upper extremity ROM was limited to prevent placing stress on her internal jugular catheters, but this did not preclude glenohumeral joint mobilization. In addition, active assistive ROM was begun as she became more alert. Consults for occupational therapy (OT) and speech therapy were recommended as Jane attempted to mouth words but became frustrated with her inability to communicate.

Re-examination (HD 9)Team discussions resulted in agreement that the goal

for Jane would be that she would be cognitively alert and weight bearing/ambulatory prior to receiving a lung trans-plant. While Jane was awake and following commands, she remained lethargic. She had gross muscle atrophy consistent with strength of ~2/5 in all key upper and lower extremity muscle groups, but her strength diminished with multiple repetitions. She was able to maintain stable vital signs when positioned in a semi-upright position (bed in the “chair position”).

Clinical ImpressionJane’s most significant impairments included decreased

muscle strength, power, and endurance that limited her ability to perform simple bed mobility tasks such as rolling, bridging, or scooting in bed. Goals included sitting edge of bed without assistance and transferring from bed to chair and walking in the room with assistance.

Interventions (HD 9-14)Jane’s PT interventions are described in Table 3, which

included a progression from active exercises in bed, to resis-tive and task-specific exercise as Jane improved in strength and endurance. She sat up with the in bed in the “chair position” (~60°) twice on HD 9 with PT, OT, nursing, and respiratory therapy. From sitting upright with the bed in the “chair position,” Jane was then able to sit on the edge-of-bed (HD 10) (Figure 1). She initially required maximal assistance for sit-to-stand (HD 11) but was able to come to stand with moderate assistance, and maintain standing with minimum assistance. As she progressed, the interventions were progressed to having Jane perform higher numbers of repetitions of the tasks and to maintain upright sitting and standing for longer periods of time. In addition, PT and OT continued to provide PROM and joint mobilization as well as active assistive ROM exercises in sitting.

Clinical ImpressionContinued close attention was paid to any signs and

symptoms of poor cardiac output, including orthostatic in-tolerance (decreasing arterial BP or SpO2, increased HR, diaphoresis, pallor, and complaints of dizziness, fatigue, or shortness of breath) as well as ensuring the integrity of the ECMO cannula. Also, a respiratory therapist continu-ously monitored her ECMO flow. Even in response to ver-tical postures (sitting and standing), there were never any instances in which either her ECMO flows diminished or she appeared to have inadequate systemic oxygen delivery.

Table 2. Medication List on Initial Examination (HD 6)Drug (trade name) Drug class

tobramycin aminoglycoside antibiotic

meropenem carbapenem antibiotic

cefepime cephalosporin antibiotic

ciprofloxacin (Cipro) fluoroquinolone antibiotic

vancomycin glycopeptide antibiotic

voriconazole (Diflucan) triazole antifungal

midazolam (Versed) anxiolytic-sedative (benzodiazepine)

methylprednisolone (Solu-Medrol)

corticosteriod

pancrelipase (Ultrase) digestive enzyme

ketamine general anesthetic

famotidine (Pepcid) histamine-2 blocker

Figure 1. Jane sitting edge-of-bed on HD 11 with PT and a respiratory therapist in the foreground and another respiratory therapist and nurse behind her.


Table 3. Summary of Physical Therapy Episode of CareHD Key examination findings Physical Therapy Interventions

6 Medically sedated and non responsive PROM to all major upper extremity (UE) and lower extremity (LE) joints, stretching of plantar flexors, and application of pressure relieving ankle foot orthoses (PRAFO®) for positioning and pressure relief.

ECMO initiated

7 Medically sedated, now on ECMO, SIMV, and s/p tracheostomy

PROM continued, mother instructed in PROM and donning/doffing the PRAFOs. Right glenohumeral joint mobilization.

8 Awake, mouthing words Active assistive range of motion (AAROM) of all major UE and LE muscle groups. Recommendation for speech therapy and occupational therapy consults.

9 Awake and following commands, but lethargic. Bleeding from trach site. Bilateral UE and LE muscle strength ~2/5

AM: Patient “sat up” with the bed in the “chair position” (~60°) for ~10 min. AAROM in “sitting.” PM: Sitting with bed in “chair position” for ~15 min. Bilateral planar flexor stretches, active assisted ankle, knee, and hip flexion and extension while in sitting.

10 Alert, ready to sit up. Brief complaint of dizziness, in sitting, but MAP 87-93 mm Hg, HR 80-90 bpm, and SpO2 92-95% on FiO2 0.35. Knee extensor strength 3-/5.

Transfer from supine to sitting edge-of-bed (EOB) with maximal assistance (2 persons to assist the patient and 3 more to guide her ventilator tubes, ECMO cannulae, and other arterial and venous lines). Minimal/moderate assistance required to maintain upright sitting (more as patient fatigued). Sat edge of bed for ~40 min, intermittently performing UE and LE AAROM.

11 Eager to sit and stand. No adverse signs or symptoms related to intervention except pain at trach site and fatigue at end of session (MAP 90-108 mm Hg, HR 68-95 bpm, , SpO2 mid-90s).

UE and LE AAROM in supine. Transferred to EOB with maximal assistance. Sat EOB for 15 min with contact guard-to-minimal assistance (see Fig 1). Worked on weight shifting, reaching and scooting while in sitting. She stood twice with maximal assistance (15 to 20 sec each). Knees did not buckle in standing, but she required assistance to stand erect, presumably due to hip extensor weakness.

12 AM: Anxious and medically sedatedPM: Drowsy but motivated.

Transferred to EOB with maximal assistance. Stood twice with maximal assistance, but was able to remain standing for almost 2 min each time. Required assistance to block her knees and help facilitate hip extension.

13 Stood twice for 60-90 sec. Required only moderate assistance for sit-to-stand, then only minimal assistance to maintain standing. Sat EOB ~45 min with contact guard/minimal assistance. Performed active (gravity resisted) UE and LE exercises in sitting.

14 Off ventilator, on trach collar trial for first time (FiO2 0.40). No complaints of trach site pain, dizziness, or dyspnea. Patient excited to be out of bed. Vital signs stable throughout.

Sit-to-stand with moderate assistance. Practiced weight shifting in standing. Took 5 steps from bed and pivoted to sit in chair for the first time. Repeated 2 more sit-to-stand trials, with standing durations of ~45 sec. Sat upright in chair for ~30 min and then with feet elevated for another 90 min. Transferred back to bed, again taking 5-6 steps.

Bilateral lung transplant

ECMO. While this is not the first case report of ambulatory ECMO used as a bridge to lung transplantation,7,8 it appears to be the first pediatric case, the first in a patient with CF, and the first to describe the physical therapy management of a patient on ECMO. Two additional patients at our facil-ity with CF and acute respiratory failure have recently been successfully mobilized out-of-bed with portable ECMO prior to lung transplantation, with one patient walking over 200 m less than two weeks after being placed on ECMO.

Continuous ExaminationDue to the severe acuity of Jane’s condition, every PT

session was a re-examination. Typically, she had improved since the last visit and the intervention could be progressed, but often her condition had worsened or other complica-tions had developed (eg, bleeding or anxiety), requiring a change in plans. Even during the course of a session, her response to exercise and activity was continuously moni-tored by the team to ensure she was hemodynamically sta-ble and safe. All of the PTs and OTs involved in her care had extensive experience working with critically ill patients

OUTCOMEJane received a bilateral orthotopic lung transplant on

HD 15. When seen by PT on postoperative day 2 (HD 17), she was already off the ventilator breathing humidi-fied room air (FiO2 0.21) through a trach collar, started tak-ing her first steps the following day (HD 18), and was dis-charged from the ICU on postoperative day 7 (HD 22). By hospital discharge (HD 45), she was walking over 365 m independently on room air with SpO2 ≥ 96% with minimal dyspnea and no pain.

DISCUSSION Several recent articles in the physical therapy literature

have discussed the feasibility and safety of providing PT in-terventions, including out-of-bed mobility, for patients with invasive lines, tubes, monitors, and cardiac support devic-es.14-18 This case demonstrates that patients on ECMO may be safely mobilized by physical therapy and benefit from physical and occupational therapy in the pretransplanta-tion phase that may include mechanical ventilation and


and were accustomed to being flexible, prepared for the unexpected, and able to think on their feet as they continu-ously re-examined her response to treatment.

Interventions and RationaleOften patients in the ICU are seen as lower priority

patients, but this attitude may be changing.19 Since the medical team wanted to make sure she was cognitively and physically able to participate in post-transplant rehabilita-tion, Jane was considered a high priority patient, receiving 12 physical therapy sessions during her 8 days on ECMO prior to receiving her lung transplant. As seen in Figure 1, Jane required the assistance of numerous health care pro-fessionals during mobility activities. The interdisciplinary team spent additional time coordinating schedules to ac-commodate nursing and respiratory therapy interventions.

Specific physical therapy interventions ranged from therapeutic exercise, manual therapy, and integumentary protection techniques to airway clearance techniques. As noted in Table 3, therapeutic exercise encompassed the bulk of interventions. As soon as Jane was able, we pro-gressed her exercises from active exercise in bed, to re-sistive, task-specific performance training to increase her lower extremity strength, power, and endurance. Since she initially (HD 11) required maximal assistance for sit-to-stand, this represented “high-intensity” resistance training for her lower extremity extensors. As she became stronger and required less physical assistance to stand, her “relative intensity” of resistance training was lower, allowing us to increase the number of repetitions and increase her muscu-lar and cardiovascular endurance.

Sitting upright, initially with the bed in the “chair po-sition,” and then later sitting on the edge-of-bed benefit-ted Jane by allowing her to maximize ventilation/perfusion matching, ease her work of breathing, and mobilize her secretions.20 Sitting on the edge-of-bed was also a thera-peutic exercise that strengthened Jane’s core/trunk muscles and improved balance while reconditioning her cardiovas-cular system by being in a more vertical posture.20 Con-tinued close attention was paid to any signs and symptoms of poor cardiac output, including orthostatic intolerance (ie, decreasing arterial BP; increased HR; decreasing SpO2, diaphoresis, pallor, and complaints of dizziness, fatigue, or shortness of breath).

We did not specifically work on rolling in bed and supine-to-sit transfers. In order to protect the ECMO can-nula and reduce sheer stress on her sacrum while moving in bed, the transition from supine to sit was a maximal as-sist to dependent transfer. Also in an effort to protect the ECMO cannula while maintaining or increasing glenohu-meral capsular extensibility, joint mobilization was substi-tuted for full shoulder PROM on the right.

Airway clearance is always a concern in patients with CF. In this case, an intervention, intrapulmonary percussive ventilation, with similar efficacy of postural drainage, percus-sion, and vibration,13 was provided by respiratory therapy on a frequent basis throughout the day. This allowed PT to con-centrate on exercise interventions, which often required 60

to 90 minutes per day. In addition, the upright positioning, spontaneous deep breathing that occurred during physical activity, and coordinated deep breathing with upper extremi-ty exercise provided a stimulus for mobilization of secretions.

Potential Medical Complications Although thrombus and infection are also risks of veno-

venous ECMO, bleeding and decannulation are the major concerns when mobilizing patients on ECMO.21 Jane did have several episodes of bleeding at her tracheostomy site that disrupted her therapy schedule. During mobility inter-ventions, great care was taken by the interdisciplinary team to manage her tubing to prevent tension from being placed on either her internal jugular cannula or her tracheostomy tube that could have further exacerbated her bleeding or led to decannulation.

Although Jane was not specifically diagnosed with a critical illness myopathy and/or neuropathy, neuromuscu-lar abnormalities occur in approximately 50% of patients requiring prolonged mechanical ventilation, is more com-mon in women, and may be associated with glucocorticoid use.22 Although her daily dose of methylprednisolone (20 mg per day) was not excessively high, glucocorticoids can impair muscle function by increasing protein degradation and decreasing protein synthesis,23 and could have resulted in her significantly impaired muscle strength.

CONCLUSIONThere is increased interest in early mobilization for pa-

tients in the ICU.24,25 We report on a novel population of patients who benefit from PT in the ICU, those on porta-ble ECMO. As portable ECMO becomes a more common bridge to lung transplantation, mobilization of patients in the ICU while on ECMO will be needed to maintain or increase patients’ physical function and psychological well-being while awaiting transplantation. This case dem-onstrates that a coordinated, interdisciplinary team effort can be safely used to meet these goals of patients on ECMO awaiting lung transplantation.

ACKNOWLEDGEMENTSWe thank our willing and dedicated patient and her

family for blazing a new path for the many patients that will continue to follow in her footsteps at our facility and around the world. Her success was made possible by an innovative and committed interdisciplinary team of physi-cians, surgeons, nurses, respiratory therapists, occupational therapists, and physical therapists. In particular, we would like to thank the therapists from the Department of Physical and Occupational Therapy that frequently saw Jane: Whit-ney Diebolt, OTR/L; Erin Diebold, PT, DPT; Bethany Yoder, PT, DPT; and Heidi Pongracz, PT, MPH, as well as David Zaas, MD, MBA, Medical Director of Lung Transplantation, Duke University Health System.

This work was supported by the Cystic Fibrosis Founda-tion (RDP464) and the National Institutes of Health (P30 DK072482).


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Using Simulation and Patient Role Play to Teach Electrocardiographic Rhythms

to Physical Therapy StudentsNancy Smith, PT, DPT, GCS; Sharon Prybylo, PT, DPT; Teresa Conner-Kerr, PT, PhD, CWS, CLT

Winston Salem State University,Winston Salem, NC

Address correspondence to: Nancy Smith, PT, DPT, GCS, Winston Salem State University, 601 S. Martin Luther King Dr., FL Atkins 340, Winston Salem, NC 27110 ([email protected]).

ABSTRACT: Purpose: The aims of the study were to differentiate: (1) physical therapy (PT) students’ preferred method for learn-ing electrocardiographic (ECG) recognition utilizing stan-dardized patient (SP) and human patient simulation (HPS) approaches, (2) the impact of HPS or SP on confidence in interpreting ECG, and 3) the effect of HPS or SP on stu-dents’ ability to make clinical decisions based upon ECG interpretation. Methods: “Three educational methods were employed to teach ECG recognition to two different years of novice PT students enrolled in a cardiopulmonary physi-cal therapy class. First, all students had a traditional lecture on ECG. Following the lecture, two problem-based learn-ing (PBL) approaches were utilized. One approach used a SP and paper ECG strips, and the second approach utilized HPS with simulated ECG monitoring.”1 Following the two PBL approaches, a post instructional survey regarding the learning experiences was conducted. Following instruc-tion, each cohort (n=24, n=29) of PT students was given a mixed methods survey about their experience. Results: Survey return rate amongst both cohorts was 77%. Inde-pendent sample of individual cohort and paired t-tests of combined data comparing HPS to SP revealed a strong preference for HPS (p=0.003 (2008 cohort) and p=0.0001 (2010 cohort)) and combined cohort (p=0.0001). There were no significant differences in responses between co-horts or preference between the HPS method and the use of SP and HPS combined. Additionally, 75% of respondents either strongly agreed or agreed that they felt confident with their skill in ECG interpretation as presented with HPS or SP. 90% either strongly agreed or agreed that they under-stood how the ECG relates to patient treatment. Summative assessment utilizing HPS revealed that students were com-petent in their performance in ECG recognition and clinical decision making related to patient treatment.1 Conclusion: Data support that HPS was the preferred method to improve student confidence in ECG recognition and interpretation.

Key Words: human patient simulation, electrocardiography, critical care management, educational technology

INTRODUCTION Clinical complexity in the acute care setting is increas-

ing with the advent of early mobility in the intensive care unit, especially with patients with primary and second-ary cardiopulmonary dysfunction.2-7 As early mobility of patients occurs, educators are challenged with devising strategies to teach students how to integrate the physical assessment of the patient with the complex information provided by physiologic monitoring, while ensuring pa-tient safety.7,8 As noted by Stiller5, the need to determine safety of treatment through observation of patient response via hemodynamic and ECG monitoring is paramount prior to institution of treatment, during treatment, and following treatment. Safe handling practices, knowledge of poten-tial aberrant responses, and rapid clinician response must be ensured with treatment in this setting since therapy “is used with the specific intent of challenging the patient, to provoke, among other things, cardiovascular or respiratory responses.“5 With the aim of teaching students to perform effectively in the high stakes intensive care environment where complex integration of information is vital to pa-tient safety, educators are searching for teaching strategies that accurately simulate this environment and its unique challenges. New teaching methodologies are required that strengthen student clinical decision-making in an environ-ment that requires rapid integration of immediate patient responses and feedback from complex physiological moni-toring systems. One such educational method that is cur-rently being developed to address these needs to educate students on complex acute care issues is human patient simulation (HPS).

Historically, a problem-based learning (PBL) approach with the use of role-play and a standardized patient (SP) or a traditional lecture and laboratory format have been utilized as established methods for teaching students in physical therapy education.9 Currently, a new pedagogy is evolving that employs the use of high fidelity computer-enhanced mannequins (CEM) with a great degree of physiologic and physical realism. HPS involves an active or applied learn-ing approach similar to those used with SP, with progres-


sion of scenarios from simple to complex, but employs a CEM rather than human actor. One benefit of the high fidelity CEMs over SPs in certain learning activities is the ability to actively program and visually observe accurate pathophysiological responses in the CEM in response to a therapy or intervention. CEMs may also be programmed to display a range of physiological responses, whereas the hu-man actor cannot actively change their inherent physiology (ie, initiate an abnormality on ECG at will).

Use of high fidelity CEMs in physical therapy educa-tion is in its infancy. A paucity of research exists to support the validity of HPS in physical therapy education, or in the preference for use of HPS over other learning methodolo-gies by PT students. However, several studies are avail-able on the utility and preference for integration of HPS into medicine and nursing education.10-14 One explanation for this preference for learning utilizing HPS could relate to the realistic, active and visual learning experience encoun-tered when utilizing HPS, which has been supported in the literature.12,13 From the authors’ experience, it would seem that PT students have similar preferences for HPS as an ac-tive mode of learning due to the distinct learning style of a physical therapy student; a style that is characterized by active, kinesthetic learning.15

LITERATURE REVIEWIn physical therapy education, there has been an in-

creasing focus on enhancing students’ abilities to perform clinical decision-making skills, especially in high acuity en-vironments such as the intensive care unit.16 With the tran-sition to the Doctor of Physical Therapy degree, graduates are expected to perform with increased clinical proficiency and evolve into autonomous practitioners with enhanced diagnostic and evaluative skills that include the manage-ment of critically ill patients. In spite of this, the authors note that in their experience, fewer critical care rotations are available that allow students to develop autonomous practice in this setting.17 Clinical instructors at acute care sites have decreased time to teach the students whom they are supervising due to increased productivity demands and decreased reimbursement for services provided. This de-crease in clinical mentoring time may reduce the level of mastery of critical care evaluative and treatment skills that students are able to attain during their rotation. It is also noted that patients referred to physical therapy within the acute care setting often exhibit a higher acuity of illnesses concurrent with the emphasis on early mobility.2-7 There-fore, physical therapy students must progress in their skills from novice to entry-level at a faster pace than previously required in order to function in the present-day clinical en-vironment.

This need for rapid progression of learning and the dif-ficulty of realistically preparing the students for the chal-lenges and complexities of contemporary practice has been identified by Hayward et al.16 Additionally, in preparation for students treating patients that are of higher acuity, edu-cators today must emphasize the relevance of their subject matter. If learning is not contextualized within a relevant

experience, material may be learned on a superficial level and quickly forgotten.18 For deeper learning to occur, the pedagogical approach must incorporate: appropriate se-quencing of learning, assessment methods focused on reflective observation and clinical reasoning, interactiv-ity, linking of new and previous knowledge, and discus-sion with classmates that is either faculty or learner facili-tated.18,19 The attainment of deeper learning of the subject material is evidenced by integration of content into clinical practice.18 It is with the aim of integration that the use of HPS or SP as a problem-based learning approach may en-courage progression to deeper learning.

In the context of facilitating deeper learning, features of HPS or SP must be considered. Both HPS and SP can facilitate deeper learning through their ability to present se-quenced, realistic cases, which are contextualized to the level of the learner. Additionally, these experiences foster reflection on knowledge gained and performance through group and individual assessment with debriefing and dis-cussion following the experience. However, a contextual difference does exist with the use of HPS in its ability to present accurate physiologic responses. This ability to demonstrate actual physiological changes may provide a distinct advantage to using HPS in the development of deeper learning with physical therapy students. The real-ism needed for deeper learning may be reflected in scenar-ios where complex acute care or cardiovascular conditions need to be modeled, or when interpretation of physiologic data including ECG monitoring needs to be facilitated.

Both HPS and SP have been shown to enhance student progression to deeper levels of learning that is paramount for the mastery of clinical skills. Boissanault et al.9 cited benefits from SP utilization in fostering deeper learning with improved ability to perform a screening examination, improved scores on written exams, and enhancement of incorporation and application of knowledge in physical therapy students. Similarly, Shoemaker et al.10 have noted evidence for creation of deeper learning utilizing HPS in physical therapy students. In this study, the authors ob-served a HPS experience related to skills needed in the in-tensive care unit and cited: the amount of knowledge that the students gained over traditional teaching methods was greater; the students demonstrated the ability to critically think and react to a changing situation; instructors and oth-er students could assess performance; and the experience resulted in ability to increase self-confidence with the per-formance of psychomotor and critical thinking tasks vital to the intensive care setting.10

Due to the benefits cited in the literature to both SP and HPS, the authors sought to design a simulated experience related to ECG interpretation. Therefore, the purpose of this study was to employ both HPS and SP methodologies followed by survey and summative assessment in order to (1) assess students’ preferred method for learning, (2) com-pare the impact of the approaches on confidence in clinical decision making, and (3) ascertain comfort and skill with making clinical decisions about patient treatment related to the presentation of ECG cases.


METHODSParticipants and Educational Method

The Winston Salem State University (WSSU) Institu-tional Review Board approved this project. Two groups of students enrolled in the required cardiopulmonary course in subsequent years (2008 and 2010 year-cohorts) partici-pated in the study. In the first year of the study the 2008 year-cohort completed the survey instrument as part of a curricular assessment, no identifying information was collected, and retrospective approval was obtained for use of data for publication. The same survey instrument was utilized with the 2010 year-cohort of students after informed consent was obtained. A survey was not col-lected in 2009, due to the lack of a cardiopulmonary class offering that year. There was no difference in the survey instrument, timing of survey distribution, teaching meth-ods, or any other methodology between the two cohorts including data analysis.

Both year-cohorts were taught methods for interpreta-tion of normal and abnormal ECG rhythms through a tra-ditional lecture. The course curriculum for this lecture re-mained consistent between years and was taught by the same instructor. This lecture was followed by a problem-based laboratory experience in which a SP and then a CEM were employed, which also remained consistent between years. The SP and HPS experiences were outlined accord-ing to the principles of Jefferies and Rizzolo.20

To reduce bias towards educational method, a cross-over design was utilized with each year-cohort group that participated in the learning experience. Students in each year-cohort of the class were initially divided into two equal groups by random assignment: one that had the HPS experience first followed by the SP experience, and one group that had the SP patient experience followed by the HPS experience.

During the SP experience, the instructor playing the role of the patient (SP) presented a standardized script con-taining verbal cues related to symptoms present with the represented ECG rhythm, utilizing standardized paper ECG tracings obtained from Wikimedia Commons and the ECG Learning Center.21,22 From the presentation, students were asked to make a treatment decision based upon the strip and symptoms presented. Following the presentation by the SP, a debriefing session was held to discuss the ECG tracing interpretation and the appropriateness of treatment deci-sions the students made during their interactions.

With the HPS experience, an iStan CEM, with physi-ologic modeling provided by METI HPS 6.0 software, (Medical Education Technologies Incorporated; 6300 Ed-gelake Dr; Sarasota, FL 34240) was utilized to generate and display ECG rhythms on a monitor for interpretation (see Figure) while symptoms were presented via the voice of the CEM utilizing the SP actor with an identical script to the SP experience. Students were again asked to interact with the simulator and make a treatment decision based upon the physiologic monitoring, vital signs presented, and the symptoms the simulator reported. Similarly to the SP experience, a debriefing session for the HPS was held to

discuss the ECG rhythms presented on monitoring and the appropriateness of treatment decisions made.

Evaluation of ExperienceFollowing the teaching session, students from each co-

hort were recruited to participate in a survey. The survey (Table 1) was conducted with a convenience sample via a mixed method survey design, utilizing a 5-point Likert scale and qualitative questions that addressed the learning experience. Qualitative and quantitative data were col-lected in the aim of assessing students’ preferred method for learning ECG interpretation, students’ perceived con-fidence in ECG interpretation, and perceived confidence towards clinical decision making as related to the impact of ECG findings on patient treatment. Additional qualita-tive questions were directed towards suggestions for added learning experiences that addressed ECG recognition, and changes needed to enhance the learning experience. In addition to the survey, all students were evaluated with a summative assessment utilizing a practical exam with HPS at the end of the course to assess mastery of the material.

Table 1. Survey Questions

5 point Likert Scale Questions1. The handout for ECG with the simulated patient was more helpful

to my learning than using the simulated rhythms with the human patient simulator.

2. The simulated rhythms with the human patient simulator were more helpful to my learning than using the handout with the simulated patient.

3. I feel that the use of both the simulated patient and human patient simulator was the most effective way for me to learn

4. Based on my classroom experience, I feel that I have a good understanding of the ECG and how it relates to patient treatment

5. I feel confident in interpreting ECG from live monitoring as presented with the simulator.

6. I feel confident in interpreting ECG from rhythm strips as presented with the simulated patient.

Free Response QuestionsDo you have any suggestions for further learning experiences as related to the ECG?

Is there anything you would change related to the learning of the ECG?

AnalysisFollowing student completion of the survey instrument,

quantitative analysis was conducted utilizing SPSS statisti-cal software (SPSS 19 for Windows Release 19.0.0. 2011). Frequencies and descriptive statistics were computed from the Likert scale data. An independent samples t-test was selected to compare mean responses to questions about the use of SP and HPS to determine if a difference existed between responses provided by each year-cohort. If no dif-ference existed, the cohort-year groups were combined for further analysis. In addition, an independent samples t-test was utilized to establish if a significant difference existed in responses that identified preferred learning method within a single cohort. Finally, a paired t-test was utilized to com-pare differences in questions from combined cohort Likert scale data. To reduce the presence of Type I error, nonpara-


metric tests were run to confirm the results of the paramet-ric tests. Significance was set at p < 0.05 for all analyses.

Further qualitative analysis was conducted utilizing an inductive, content analysis method.23,24 First, direct tran-scription was taken from the survey instruments. An initial coder developed themes from the lines of data from the most commonly occurring words identified by an elec-tronic word search and categorized each line into a theme category. The direct transcription was then given to two separate observers to reduce coder bias and increase coder reliability. These observers performed independent anno-tation of the data in a line-by-line analysis to discover the most common themes or phrases present within the data in response to each question. Each observer then noted their individual themes using a constant comparative method and recorded them. After each independent coder finished recording their themes, themes and category placement were compared for inter-coder agreement in theme defini-tion and category placement. The initial coding produced a theme definition and category placement agreement of 90%. Each coder coded data again until all lines con-formed into a category and until 100% agreement was reached for classification of each line of data into a theme, which occurred for two separate coding sessions.

RESULTSThe overall return rate on the survey was 77% (n=41,

first cohort 91% (22/24), second cohort 66% (19/29)). Co-hort characteristics are noted in Table 2. There were no statistically significant differences in responses found be-tween years (Table 3). A comparison of individual cohort (p=0.003 (2008 cohort) and p=0.0001 (2010 cohort)) and

combined cohort (p=0.0001) Likert data revealed a strong preference for HPS over SP. These findings were confirmed by non-parametric statistics (p=0.001 for individual cohort and combined cohort). Additionally, when the HPS method and the use of SP and HPS combined methods were com-pared utilizing combined cohort data; there was no sig-nificant difference in preferred method (p=0.08). Further analysis showed that, 75% (n=30) either strongly agreed or agreed that they felt confident with their skill in inter-pretation of ECG rhythms as presented with HPS or with rhythm strips, and 90% (n=37) either strongly agreed or agreed that they had a good understanding of ECG as it related to patient treatment.1 When a summative practical exam utilizing HPS was conducted to evaluate knowledge pertaining to ECG, 100% of students made correct identi-fications of ECG rhythms and proceeded to make correct clinical decisions when presented with cases incorporating ECG monitoring.

From the questions on learning experiences and sugges-tions for change in experiences, certain themes emerged. A comprehensive list of themes and supporting statements is outlined in Table 4. The following themes were found across both open ended response questions: more case studies with HPS or SP, more time with simulation, smaller group size, more practice, immediate debriefing needed following each rhythm presentation, the simulator is pre-ferred, and the monitor is a good visual tool. On question one, students also cited that the overall learning experience was very helpful. With question two, the theme that the monitored rhythms do not look like the strips emerged.

DISCUSSION The results of the study show a strong predilection

towards HPS as a preferred method for learning ECG in-terpretation in physical therapy, which is a novel finding. This preference is consistent with results from other studies published in other disciplines.13,14 Similar to other studies, students cited that: they wanted more time with HPS, more practice was needed, that the experience was helpful, and more experiences utilizing simulation were needed to as-sist them in better application of their knowledge.10

When considering the application of knowledge us-ing HPS compared with a combined approach utilizing SP and HPS; the students prefer HPS alone. This finding is interesting to note, since no previous study has compared a preference for learning between SP and HPS. In consider-ing this preference, one must consider the major difference in the two techniques; the physiologic realism provided by the simulator. Since realism is important in the deeper ac-quisition of context-based instruction,19 it stands to reason that HPS should be considered as an alternative teaching method to SP in scenarios where a high degree of physio-logic realism is needed to assist in clinical decision-making processes.

Even though there was strong support and more desire for the use of HPS to facilitate learning, students stated that they did like having the paper strips provided with the SP, to reinforce their learning, and to assist in distinguishing pos-

Table 2. Cohort Characteristics COHORT 1---CLASS OF 2009

COHORT 2—CLASS OF 2011

N 24 29

Gender 30.8% Male69.2% Female

24.1% Male75.9% Female

Mean Age 27.7 25.2

Race African American 34.6%White 57.7%Other 27.7%

African American 17.2%White 79.4%Other 3.4%

Table 3. Summary of Cohort DifferencesQUESTION MEAN SCORE

GROUP 1 MEAN SCORE GROUP 2

P VALUE

Question 1Question 2Question 3Question 4Question 5Question 6

2.864.144.244.243.863.95

3.153.644.204.003.633.70

0.4270.0890.8750.3140.2730.103

significance set at p=.05


sible confusing information provided by the monitor. This theme could be related to the assertions of the problem-based learning literature, in which students require some level of foundational knowledge prior to proceeding to

Table 4. Qualitative ThemesTHEMES FROM QUESTION ONE SUPPORTING STATEMENTS

More case studies with HPS or SP “Incorporate more scenarios with moving robot during various ECG.”“More case studies related to ECG changes”“I liked the combination approach.”

More time with simulation “More time with simulated rhythms on human simulators.”

Smaller group size “Smaller groups in each group”“Continue to use the simulator with small group size.”“More interactive with it.”

More practice “More on interpretation of heartrate.”“Additional ECG labs with the standardized patient would have been beneficial.”“The more exposure the better with variety of strips for the same condition.”

Immediate debriefing needed following each rhythm presentation

“It would be more beneficial to review each rhythm as it is shown. Visual learners especially benefit from seeing the rhythm while reviewing correct info about it.”“Explain each rhythm and what that rhythm is as we go through it.”“Deal with one rhythm at a time and discuss all its aspects.”“Talk about the ECG after questioning the patient.”“Go through each abnormal rhythm and discuss what is missing, not missing, etc regarding the waves.”“Sequence of presentation—look at ECG and discuss each more in depth.”“Explain monitor results while going through scenario instead of reviewing results afterward.”

Simulator preferred “The simulator was very helpful to learn and understand the ECG, it simulates a real-life experience, it is better.”

Monitor is a good visual tool “The ECG screen is helpful and the robots don’t seem to add too much.”“The monitor let me see rhythms while they were happening.”“Excellent tool—good visual aid to learning”

Overall experience very helpful “Very helpful for learning ECG.”“The ECG was very helpful to me.”

THEMES FROM QUESTION TWO SUPPORTING STATEMENTS

More time with simulation “Spend more time with simulator”

Monitor is a good visual tool “Liked visually seeing the rhythms on the monitor”

Simulator preferred “The standardized patient made my learning a little difficult.”“I liked the different ECG presentations of the simulation with verbal cueing from operator.”“Learning from the simulator during lab was better for long-term clinical exposure.”“I was able to learn more from simulation than I would have without the simulation.”“Liked seeing changes in patient response/signs (with simulation).”“I don’t think the live patient helped me learn anything.”

More practice “More practice strips, possibly on blackboard, so we can practice reading ECG’s”“Hook up a few live patients from the class to see a live model.”“Clinical scenario practice in front of human simulator where the ECG changes and we have to recognize the change.”“The strips are a good starting point, but if we could see more strips of the same condition could be helpful.”“Would like to have more class sessions with live monitoring for further practice and review”“More online tools to assist us with learning them”

Monitored rhythms do not look like the strips “Identification of rhythms may be confusing due to computer program.”“Sometimes the (monitored) rhythms do not look like the strips.”

Smaller groups “Smaller groups.”“Smaller group sizes.”

More case studies with HPS or SP “Hook up a few live patients from the class to see a live model.”“Clinical scenario practice in front of human simulator where the ECG changes and we have to recognize the change.”

Immediate debriefing needed following each rhythm presentation

“Compare and contrast the rhythms.”“It would be better to have visible symptoms on the simulator and discuss each rhythm as it comes.”

solve a more complex patient case.20 From this finding, it seems that instructors should spend more time emphasiz-ing early training in a standardized format prior to progres-sion to a more dynamic format, like HPS. This early train-


ing would ensure that students have adequate foundational knowledge in order to perform integrated learning utilizing HPS. Training to establish this knowledge could be facili-tated with laboratory experiences, lectures, or with partial-task trainers (usually low technology, models of specific regions of the body) prior to proceeding to higher fidelity (computer-enhanced) methods of simulation, which tend to require a high degree of integration. It should also be noted that the theme emerged that monitored ECG rhythms do not look like paper ECG tracings. In this light, students should be didactically prepared to interpret both paper-based and electronically monitored ECG rhythms, since either paper-based (static) forms of ECG and electronic (dynamic) forms of ECG are used in clinical practice.

The students identified the value of immediate debrief-ing and smaller group interaction. While a summative de-briefing was performed to foster reflection, the students de-sired an immediate debriefing following each rhythm pre-sentation to facilitate more immediate clarification. Both themes are consistent with the problem-based and deep learning literature.19,25

There are several limitations to the study. While this sample was one of convenience, the original objective was to study the effectiveness of implementation of HPS or a SP into teaching ECG in a cardiopulmonary physical ther-apy class as a new teaching method. Future studies could randomize assignment into groups that involved a control group of traditional lecture, and two intervention groups, one that utilized SP, and one that utilized HPS in order to provide a better sampling comparison.

Another limitation of this study was the lack of pre-test survey that addressed preference towards the different edu-cational methods employed or confidence in ECG inter-pretation prior to the educational interventions. This pre-test survey was not conducted due to the fact that students did not have prior experience working with a SP, therefore, they would not be able to address the questions directed towards the use of a SP appropriately prior to the interven-tion. In spite of the lack of a pre-test survey, which may have more conclusively indicated decreased confidence in ECG interpretation prior to the intervention, there were multiple comments directed towards the instructor of the cardiopulmonary class by students participating in the learning experience. Many students stated limited confi-dence in interpreting and understanding ECG interpretation and limited understanding of how to effectively assess and manage patients with cardiac arrhythmias. Additionally, the survey did not address a preference for traditional lecture as a preferred strategy for learning; however, the goal of the study was to identify the differences between HPS and SP as learning methodologies for ECG.

The overall effect of the educational methods employed on confidence and performance on the summative exam may have resulted from an interference effect between teaching methods used. Since multiple methods were uti-lized in teaching the students, reinforcement and repetition was provided, which limits the ability to conclude which method had the most effect upon knowledge gained and

confidence. However, such a strong preference existed in favor of simulation as the learning methodology of choice, that further studies should address confidence and knowl-edge gained produced solely from HPS in a pre and post-test manner.

From the questions asked, it is not known if HPS in-creased safety during clinical rotations. However, anec-dotal evidence from interviews during clinical site visits in-dicated that students that had this learning experience were more confident than previous students who did not have the learning experience in their ability to read the electron-ic monitors and to safely handle patients. In at least two documented cases, students that had experiences with HPS exhibited skill in handling high acuity patients. They were able to respond to emergent situations involving changes in the ECG and were able to effectively communicate their clinical decisions to the clinical instructors and physicians. Further study should be performed, however, to validate this transfer of training to clinical practice.

Students did not differ significantly in their responses to the preferred educational methodology across cohorts, however when cohort responses were compared, Question 2 did approach a statistically significant difference between the two cohort groups. This could be due to the fact that stu-dents may indeed prefer a method of learning in a dynamic, visual manner that emphasizes realistic practical skills that informs clinical practice, but may need the reinforcement of the material by a learning method (paper strips), which is less dynamic. This finding is consistent with the qualita-tive responses provided by the cohorts. However, further longitudinal study is required to see if this result remains consistent in future cohorts.

CONCLUSIONSInitial data support HPS as the preferred method for

improving physical therapy student confidence in ECG recognition and interpretation. HPS appears to provide a pedagogical approach that enhances learning experienc-es and assists students in applying classroom knowledge successfully during competency testing. Simulation tech-nologies provide physical therapy educators with an edu-cational approach that can be used to create real world experiences that were previously impossible with tradi-tional lecture or even SPs in order to facilitate success-ful application of knowledge for deeper learning of the material. HPS also provides an opportunity for students to train in a controlled environment without associated risk to patients. As a result, students can be exposed to evaluation and treatment strategies that may prove helpful in new clinical situations.

ACKNOWLEDGEMENTSSpecial thanks to Dr. Jiangmin Xu for his assistance with

SPSS and statistical measures. Thanks to Dr. Lynn Millar for her assistance with statistical measures.

This work was funded by a CRAA Title III Special Project Grant, US Department of Education, Virtual Health Commu-nity; with Teresa Conner-Kerr as the principal investigator.


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PresidentEthel M. Frese, PT, DPT, MHS, CCSSt. Louis UniversityDepartment of Physical Therapy3437 Caroline StreetSt. Louis, MO 63104W: 314/977-8535FAX: 314/977-8513E-mail: [email protected]

Vice PresidentChris Wells, PT, PhD, CCS, ATCUniversity of Maryland School of MedicineDepartment of Physical Therapy & Rehabilitation ServicesSuite 215C, 100 Penn StreetBaltimore, MD 21201W: 410/706-6663FAX: 410/707-6387E-mail: [email protected]

SecretaryKristin M. Lefebvre, PT, PhD, CCSWidener UniversityInstitute for Physical Therapy Education111 Cottee HallOne University PlaceChester, PA 19013W:610/499-1148E-mail: [email protected]

Treasurer & FinanceAnn Fick, PT, DPT, MS, CCS1042 ParkwatchBallwin, MO 63011W: 314/362-2720E-mail: [email protected]

ProgramDaniel Malone, MPT, PhD, CCS3035 S Jericho CtAurora, CO 80013E-mail: [email protected]

Legislative & ReimbursementEllen Hillegass, PT, EdD, CCS, FAACVPR220 Lackland CourtDunwoody, GA 30350W: 770/846-0350E-mail: [email protected]

Public Re la tions/BoothBobby Belarmino, PT, DPT, MA, CCSDepartment of Physical TherapySchool of Public HealthNew York Medical CollegeValhalla, NY 10595W: 914/594-4907FAX: 312/864-9746E-mail: [email protected]

Public Relations/Web sitePamela Bartlo, PT, DPT, CCSD’Youville College320 Porter Ave.Buffalo, NY 14201W: 716/829-8390FAX: 716/829-7680E-mail: [email protected]

MembershipDawn Stackowicz, PT, MS, CCS4428 N. Dover St. #1Chicago, IL 60640W: 312/864-3650FAX: 312/864-9746E-mail: [email protected]

EducationJennifer Ryan, PT1208 Woodland Heights Blvd.Streamwood, IL 60107Cell: 630/649-8331Fax: 847/429-3011E-mail: [email protected]

NominatingNancy Cielsa, PT, DPT4048 Stansbury Mill RoadMonkton, MD 21111H: 443/310-1814email: [email protected]

JournalAnne Swisher, PT, PhD, CCSDivision of Physical TherapyWest Virginia University PO Box 9226Morgantown, WV 26506W: 304/293-1319Fax: 304/293-7105E-mail: [email protected]

Research ChairChristine Wilson, PT, PhDUniversity of the PacificDepartment of Physical Therapy3601 Pacific AveStockton, CA 95211W: 209/946-2397FAX: 209/946-2367E-mail: [email protected]

Specialty CouncilJeffrey Rodrigues, PT, CCS3502 Canehill AvenueLong Beach, CA 90808W: 323/442-5344E-mail: [email protected]

Fund Raising CommitteeDianne V. Jewell, PT, DPT, PhD, CCSVirginia Commonwealth UniversityDepartment of Physical TherapyPO Box 980224Richmond, VA 23298-0224W: 804/828-0234FAX: 804/828-8111E-mail: [email protected]

Officer/Committee Chair Directory

Cardiopulmonary Section Web sitehttp://cardiopt.org

Cardiopulmonary Physical Therapy Journal Web sitewww.cpptjournal.org

CardiopulmonaryPhysical Therapy JournalAmerican Physical Therapy Association2920 East Avenue South, Suite 200La Crosse, WI 54601

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