1. Rehabilitation after critical illness
Lisa ronson Critical Care Physiotherapist

2. 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.

3. What are the effects of immobility and critical illness?

4. 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

5. 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

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

7. 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

8. Limb care and positioning

9. 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

10. Limb care and positioning

11. 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

12. 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?

13. 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