No effect of early cycling exercise in ICU

Guillaume Fossat,  Florian Baudin,  Léa Courtes et el  published a trial of in-bed cycling exercises and electrical stimulation versus standard rehabilitation in critically ill patients. 

BACKGROUND

About half of patients admitted to Intensive care units experience muscle weakness and wasting which may persist for up to 5 years.  Factors contributing are inflammation, metabolic disorders, sedation and prolonged mechanical ventilation.

Early mobilization has shown to be safe, but had no impact on short- and long-term mortality, but may improve mobility status, muscle strength and days alive and out of hospital to 180 days. It has shown to prevent ICU-acquired weakness, shorten ICU and hospital stays, decrease the incidence of delirium, and reduce the time until return of functional autonomy.

Exercises using a cycle ergometer may improve the strength of the quadriceps muscles and perceived quality of life at hospital discharge.  Electrical muscle stimulation may reduce muscle atrophy in ICU patients.

WHERE

Single center 20 bed med surg ICU in Orléans, France.

PATIENTS

Aged 18 years or older, who were admitted to the ICU less than 72 hours before randomization,  who were deemed to need more than 48 hours of care in the ICU, and  had an independent walking ability and a Barthel Index  greater than 55 within 15 days before ICU. 

Following patients were excluded

Pregnant, cardiac arrest patients, pacemaker or ICD, stroke, GB syndrome, Myasthenia, dementia, DVT or PE, amputated lower limb, and those who had contraindication to standing.

INTERVENTION AND METHODS

In the intervention group, in addition to standardized early rehabilitation (see below), each weekday, the patients underwent a 15-minute session of leg cycling exercise (even in bed) on a cycle ergometer.  At a different time of the day, a 50-minute electrical stimulation session of the quadriceps muscles delivered by a 4-channel electrical stimulator. 

In the standard group, a progressive multistep program  beginning with 10 passive range of motion exercises with each limb joint applied once every weekday by physiotherapists to comatose or sedated patients, followed by passive or active exercises and then fully active muscle exercises, transfer to the edge of the bed or to a chair, standing, and walking.

OUTCOMES

The primary outcome measure was the patient’s global muscle strength assessed using the Medical Research Council (MRC) grading system to determine the strength of 6 muscle groups on both sides of the body (overall score range, 0-60 ).

Secondary outcomes

Functional autonomy at ICU discharge, the proportion of patients who developed delirium,  the duration of invasive mechanical ventilation and the number of ventilator-free days, mortality rateswere measured during the ICU stay,
during the hospital stay, at day 28, and at 6 months.  The change in thickness of the rectus femoris muscle for each thigh, which was measured using ultrasonography (mean measurements for the left and right sides of the body), between study inclusion and ICU discharge.

Safety was evaluated as the proportion of patients who experienced at least 1 clinically significant adverse event
(defined as an event that required a therapeutic intervention beyond simple session interruption) during the mobilization sessions.

RESULTS

There were no differences in both groups, both primary and secondary outcomes.

ADVERSE EVENTS

No difference between two groups.

LIMITATIONS

Single center study, mainly non surgical septic patients and MRC score may not be the best tool to assess physical status.

BOTTOM-LINE

Whole-body rehabilitation -consisting of interruption of sedation and physical and occupational therapy in the earliest days of critical illness was shown to result in better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days compared with standard care in 2009.

However, later studies shown mixed results in various settings.

If you combine the latest 7 RCTs, following inferences can be extrapolated

  1. To be effective, mobilization should be started as early as possible(except neuro-critical care).
  2. Multi- professional approach is better than involving just physical therapists.
  3. Results have been mixed on outcomes such as muscle strength, functional capacity and mortality.
  4. Mobilization can be safely administered in intensive care unit on critically ill patients(selective).
  5. Dose of mobilization is important but we do not know how much.