Chang­ing our view on ex­er­cise for frail pa­tients

In-bed cy­cling can help peo­ple in the ICU re­cover faster and main­tain phys­i­cal strength

The Hamilton Spectator - - COMMENT - MICHELLE KHO Michelle Kho is an as­sis­tant pro­fes­sor in the School of Re­ha­bil­i­ta­tion Sci­ence at McMaster Univer­sity, phys­io­ther­a­pist at St. Joseph’s Health­care Hamil­ton, and net­work in­ves­ti­ga­tor with Cana­dian Frailty Net­work. She holds a Canada Re­search C

Frail and crit­i­cally ill pa­tients can safely bike in the in­ten­sive care unit, even early in their ICU stay. Th­ese are the ex­cit­ing find­ings from an in-bed cy­cle pro­gram that aims to get hospi­tal pa­tients — even in in­ten­sive care units — ped­alling as soon as pos­si­ble with ther­a­peu­tic bi­cy­cles, so they are func­tion­ing bet­ter by the time they leave hospi­tal.

Why throw in a fit­ness plan for pa­tients who al­ready have so many crit­i­cal med­i­cal is­sues? The rea­son is be­cause pa­tients who are stuck in bed are pre­cisely the pa­tients who need in-bed cy­cling the most.

Any­one who’s tried hit­ting the gym or re­cov­ered from in­jury knows that mus­cles can take weeks to grad­u­ally strengthen. But did you know that mus­cles only take days to quickly de­te­ri­o­rate?

For ex­am­ple, af­ter only seven days of ly­ing in a crit­i­cal care bed, one study noted that pa­tients’ mus­cle strength was four times weaker than in healthy con­trols. Af­ter 10 days of crit­i­cal care with me­chan­i­cal ven­ti­la­tion, pa­tients’ leg mus­cles de­creased in size by al­most 18 per cent.

In fact, many pre­vi­ously ac­tive pa­tients are un­able to walk when they are dis­charged from crit­i­cal care due to pro­found mus­cle weak­ness. In new re­search, my col­leagues and I show how we start to think of re­ha­bil­i­ta­tion, very early in a pa­tient’s ICU stay to help pre­vent or min­i­mize this weak­ness. What is in-bed cy­cling? The in-bed cy­cle in­volves a spe­cial­ized ex­er­cise bike that rolls over pa­tients’ beds. Th­ese cy­cles have a mo­tor, can move pa­tients’ legs for them or al­low pa­tients to cy­cle on their own. Pa­tients stay on their back while their lower legs and feet are se­cured into slings and ped­als while their legs move in a cy­cling mo­tion. The in-bed cy­cle also has video screen that helps mo­ti­vate more alert pa­tients with an­i­ma­tion of their vir­tual ride.

In-bed cy­cling is an es­pe­cially promis­ing early ex­er­cise in­ter­ven­tion be­cause it tar­gets the legs, par­tic­u­larly hip flex­ors, which are most vul­ner­a­ble to mus­cle at­ro­phy and weak­ness dur­ing bed rest.

Cy­cle ther­apy can also safely be­gin right af­ter re­sus­ci­ta­tion, while pa­tients are still at­tached to life sup­port, whether pa­tients are awake or se­dated. That’s right, pa­tients can be ped­alling even be­fore they wake up.

We re­cently con­ducted a study with frail and crit­i­cally ill pa­tients con­nected to ma­chines to help them breathe to see if they could start cy­cling very early in their ICU stay. Our study found cy­cle-ther­apy safe be­cause there were very few times where pa­tients stopped cy­cling early due to med­i­cal con­cerns — and fea­si­ble, be­cause over 90 per cent of pa­tients or sub­sti­tute de­ci­sion mak­ers who were ap­proached agreed to par­tic­i­pate in the study.

So far, our team has trained eight ICU fa­cil­i­ties and over 45 phys­io­ther­a­pists across On­tario to pro­vide in-bed cy­cling in our on­go­ing re­search. The rest of the coun­try is still wait­ing for cy­cle ther­apy.

Here’s why hos­pi­tals should re­view and ex­pand their ap­proach to re­ha­bil­i­ta­tion across the coun­try:

Pa­tients in crit­i­cal care are rigged up to all sorts of spe­cial­ized equip­ment, in­clud­ing ma­chines to sup­port breath­ing, med­i­ca­tion pumps and mon­i­tors. De­spite all this in­vest­ment, few crit­i­cally ill pa­tients re­ceive ex­er­cise, which is key to their re­cov­ery.

Stud­ies from the ICU show that ex­er­cise is more ef­fec­tive than changes in nu­tri­tion or dif­fer­ent ways of pro­vid­ing me­chan­i­cal ven­ti­la­tion for im­prov­ing long-term phys­i­cal func­tion in crit­i­cally ill adults.

But crit­i­cally ill and frail pa­tients are of­ten per­ceived as “too sick” for phys­io­ther­apy. Re­ha­bil­i­ta­tion in the ICU can be in­fre­quent and, when pro­vided, may oc­cur late in a pa­tient’s ICU stay.

With­out re­ha­bil­i­ta­tion, phys­i­cal strength quickly de­te­ri­o­rates and pa­tients wind up leav­ing ICU with new weak­nesses ac­quired in the ICU. This in turn can re­sult in longer hospi­tal stays, higher risks of mor­tal­ity and more health care costs.

It’s time to change the way we view ex­er­cise for frail and crit­i­cally ill pa­tients. As soon as we re­sus­ci­tate, we need to think of start­ing re­ha­bil­i­ta­tion in­ter­ven­tions, even in the ICU, to op­ti­mize their re­cov­ery.

Early in-bed cy­cling is one cre­ative ther­a­peu­tic ap­proach for crit­i­cally ill pa­tients, for sup­port­ing our ag­ing pop­u­la­tion, and for po­ten­tially sav­ing sig­nif­i­cant health-care dol­lars down the road.

Newspapers in English

Newspapers from Canada

© PressReader. All rights reserved.