Rehabilitation after critical illness Lisa ronson Critical Care Physiotherapist

The dangers of going to bed (Asher 1942) Look at the patient lying alone in bed What a pathetic picture he makes. The blood clotting in his veins. The lime draining from his bones. The scybola stacking up in his colon. The flesh rotting from his seat. The urine leaking from his distended bladder and the spirit evaporating from his soul. Teach us to live that we may dread unnecessary time in bed. Get people up and we may save patients from an early grave.

What are the effects of immobility and critical illness?

Consequences of immobility and illness Changes in muscle function Disuse osteoporosis Cardiovascular changes Fatigue and deconditioning Loss of dexterity Changes in connective tissue Changes in joint capsule congruency Altered cortical map Sensory system becomes overwhelmed

Guidelines for rehabilitation after critical illness NICE Guidelines CG83 (2009) and QS158 (2017) Physical and non-physical dimensions Care pathway including early assessment, goal setting, patient information and follow-up Core standards for Intensive Care Units (2013) and Guidelines for the Provision of intensive care services (2017) (GPICS) Assessment within 24 hours 45 minutes daily of each therapy, min 5 days per week Tracheostomy patients reviewed by SLT for swallow and communication ESICM Statement (2008) McWilliams (2015) - A quality improvement strategy to promote early and enhanced rehabilitation improved levels of mobility at ICU discharge as well as reducing ICU and hospital LOS and reducing days of mechanical ventilation

Different phases of intervention 1st stage: Maintenance and Prophylaxis Risk assessment 2nd stage: Early rehabilitation/facilitation 3rd stage: Active participation

Maintenance/Prophylaxis Prevention of musculoskeletal adaptations Optimisation of functional movements Normalising sensory and proprioceptive input 24 hour management – Limb care through positioning and splinting Optimisation of long term function by minimising secondary changes

Limb care and positioning

Limb care and positioning Aims Maintain joint range of movement and muscle length Provide proprioceptive and sensory stimuli Treatment options Correct position/alignment in bed Stretches Joint mobilisation Providing sensory information Splinting

Limb care and positioning

Early progressive mobilisation Evidence Can reduce ventilator time and ICU stay Reduce incidence of delirium Improvement in functional outcomes Improvement in quality of life Improvement in respiratory muscle strength Improvement in limb muscle strength

Group work Split into 4 groups and try out your piece of equipment Tilt table, motomed, seating, rotastand Discuss in your groups: How may this piece of equipment aid function? What are the benefits of using this equipment? What difficulties may arise using it in the ICU setting?

Clinical focus Guidelines and literature suggest that early rehabilitation reduces ventilator time, ICU and hospital stay, reduces delirium and improves function Aims of early rehabilitation are: To provide a ‘normal’ experience of movement To minimise the effects of deconditioning and adaptive changes To maintain functional ability To reduce length of stay in critical care Achieved by: 24 hour approach through positioning, alignment and splinting management 45 mins of daily therapy if tolerated