April 12, 2010

More benefits are found from mild exercise in critically ill

A new report from critical care experts at Johns Hopkins shows that physicians can cut back by half their use of prescription sedatives so that critically ill patients can be alert and awake to exercise more. Curtailing use of the drowsiness-inducing medications not only allows patients in the intensive care unit to participate in mild exercise, which is known to reduce muscle weakness linked to long periods of bed rest, but also reduces bouts of delirium and hallucinations and speeds up ICU recovery times by as much as two to three days, the paper concludes.

The experts say that mild exercise, with sessions varying from 30 minutes to 45 minutes, should be performed by patients under the careful guidance of specially trained physical and occupational therapists, and it can include any combination of leg or arm movements while lying flat in bed, sitting up or standing, or even walking slowly in the corridors of the ICU. The team has since evaluated a number of additional physical rehabilitation therapies, such as cycling in bed using a specially designed peddling device, or stimulating contractions of the leg muscles with overlying electrical pads. Patients can often exercise while still attached to life support equipment, such as a mechanical ventilator that helps them breathe, the group shows.

In its latest exercise report, published in the journal Archives of Physical Medicine and Rehabilitation online April 9, the Johns Hopkins team closely monitored the progress of 57 patients admitted in 2007 to The Johns Hopkins Hospital’s medical intensive care unit, or MICU. Their treatment encompassed 794 days spent in the unit. Members of the MICU team checked the patients’ records daily for several months before and after the physical rehabilitation project began. Each patient was mechanically ventilated for at least four days. Most patients did not have more than one exercising session before the enhanced exercise plan started, while more than a half-dozen physical therapy sessions in the MICU were commonplace after the plan’s implementation.

“Our work challenges physicians to rethink how they treat critically ill patients and shows the downstream benefits of early mobilization exercises,” says critical care specialist Dale Needham, who spearheaded the project.

“Our patients keep telling us that they do not want to be confined to their beds; they want to be awake, alert and moving, and engaged participants in their recovery,” says Needham, an associate professor at the Johns Hopkins School of Medicine. “Patients are not afraid of exercising while they are in the ICU, and they are embracing this new approach to their care. It actually motivates them to get well and reminds them that they have a life outside the four walls surrounding their hospital beds.”

Needham’s latest findings contribute to his team’s other research in the past three years, demonstrating in more than 500 patients how early physical rehabilitation and mild exercise helped ICU patients move about, sit and stand up. He says patients can lose as much as 5 percent per week of leg muscle mass when confined to bed rest.

In the new report, Needham and colleagues found that the use of drowsiness-causing benzodiazepines declined to only 26 percent of patient days spent in the MICU in the four months following introduction of early mobilization practices, compared to 50 percent of patient days in the three months leading up to the project. Daily doses dropped even further. Half the patients were given more than 47 milligrams of midazolam and 71 milligrams of morphine before early exercising was emphasized; after exercising became more widespread, half needed less than 15 milligrams of midazolam and 24 milligrams of morphine.

Daily episodes of delirium, when a patient may hallucinate, be unable to think straight or simply be unaware of his surroundings, were sharply curtailed. Before exercising began, ICU patients were spending as little as 21 percent of all patient days without such disturbances, but this grew to 53 percent clear-thinking days afterward. Delirium is known to occur in ICU patients who have been heavily sedated, prolonging their ICU stay and recovery.

Overall time spent in intensive care and in the hospital also dropped after exercising was promoted, by 2.1 days and 3.1 days, respectively. And with patients recovering faster, the Johns Hopkins MICU was able to treat 20 percent more patients even though its capacity, at 16 beds, remained the same.

Critical care expert Eddy Fan, a member of the project team and an instructor at Johns Hopkins, says that physicians are changing their perspective on prolonged bed rest with heavy sedation and its long-term consequences to patient health.

Fan says that developing appropriate physical therapy regimens involves careful planning and coordination among all members of the critical care team, including physicians, nurses and respiratory, physical and occupational therapists. He notes that it can take an hour to get a patient ready to perform and finish certain exercises, such as walking short distances, and that patient comfort and safety must be monitored throughout the activity.

Launching this kind of early physical medicine and rehabilitation program requires serious commitment. Fan says that the Johns Hopkins initiative involved nearly 150 hospital physicians and staff in meetings about early mobilization of patients, including 16 seminars with MICU nurses on sedation alone, as well as presentations about former ICU patients’ problems with muscle weakness after their discharge.

“Things can change quickly in the ICU, but if the patient has the energy to exercise and vital signs are OK, and the staff are trained and confident in the type of activity to be performed, then it is in the patients’ best interest to get them moving,” Fan says.

Needham says that long-term clinical studies of these treatment techniques are already under way; some critically ill patients are performing early-mobilization exercises and others less so or not at all. The goal of researchers, now that the immediate physical benefits have been shown, is to gauge if early rehabilitation therapy improves patients’ quality of life, such as their ability to stay active and mobile inside and outside the home, and to quantify any hospital cost savings accruing from the effort.

Funding support for the report was provided by The Johns Hopkins University and The Johns Hopkins Hospital.

In addition to Needham and Fan, Johns Hopkins researchers involved in this study were Radha Korupolu, Jennifer Zanni, Pranoti Pradhan, Elizabeth Colantuoni, Jeffrey Palmer and Roy Brower.

Related Web sites

Dale Needham

Eddy Fan

Videos of Needham commenting and ICU patients practicing techniques in early mobility

‘Archives of Physical Medicine and Rehabilitation’